Intraoperative phrenic nerve monitoring in cardiac surgery.
BACKGROUND
Left hemidiaphragmatic paralysis due to phrenic nerve lesion is a frequent complication of hypothermic cardiopulmonary bypass. Although this is believed to be caused by cold injury to the phrenic nerve, its exact cause is still not clear.


OBJECTIVE
To assess feasibility, safety, and usefulness of intraoperative phrenic nerve function monitoring.


METHODS
Elective cardiac surgery in a university hospital.


METHODS
Consenting patients scheduled for myocardial revascularization surgery with the use of the left internal mammary artery.


METHODS
Intraoperative monitoring of compound diaphragmatic action potentials (CDAPs) through transcutaneous stimulation of phrenic nerves.


METHODS
Patients were divided in two groups. Group 1 received intracoronary cold St. Thomas's solution as the only cardioplegic method. Group 2 received topical cardiac cooling with ice-cold solutions in addition to intracoronary cardioplegia.


RESULTS
In all group 1 patients, function of phrenic nerves was maintained throughout the surgical procedure. Group 2: in two patients, bilateral, and in one patient, left phrenic nerve conduction was abolished after submersion of the heart in ice-cold solution. In two of them, the action potential of the left hemidiaphragm was absent by the end of surgery. In one, nerve conduction recovered with rewarming of the patient.


CONCLUSIONS
Intraoperative monitoring of CDAP was safe and easily obtained in the intraoperative setting. It allowed us to observe changes in phrenic nerve conduction occurring during surgery and as a result of cold cardioplegia. Cryogenic lesion of phrenic nerve might explain our findings. However, nerve ischemia cannot be ruled out and it may worsen axonal damage or delay its recovery.


CONCLUSIONS
This monitoring method allowed us to predict postoperative diaphragmatic dysfunction. Also, surgeons can be warned of the damaging effects of excessive cooling of the pericardium and surrounding structures; thus, preventive measures can be taken.
Mazzoni
M
M
Department of Anesthesia and Intensive Care Unit, IRCCS Centro Cardiologico Fondazione Italo Monzino, Milano, Italy.
Solinas
C
C
Sisillo
E
E
Bortone
F
F
Susini
G
G
D000200:Action Potentials; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D003964:Diaphragm / Q000502:physiology; D005260:Female; D006324:Heart Arrest, Induced / Q000009:adverse effects; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009204:Myocardial Revascularization; D009431:Neural Conduction; D010791:Phrenic Nerve / Q000293:injuries / Q000502:physiology* / Q000503:physiopathology; D012133:Respiratory Paralysis / Q000209:etiology