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Ann Thorac Surg 1998;66:302
© 1998 The Society of Thoracic Surgeons

Correspondence

Reply

Dimitri J. Nikas, MDa, John A. Elefteriades, MDa

a Yale University School of Medicine, 333 Cedar St, Rm 121 FMB, New Haven, CT 06520, USA

To the Editor

We congratulate Dr Weinstein on his excellent clinical results. We appreciate his suggestions regarding technical details for use of topical slush and insulating pads.

A zero incidence of diaphragmatic paralysis after coronary artery bypass grafting is extraordinary. Unfortunately, most clinicians continue to be plagued by diaphragmatic dysfunction. It has previously been shown that the observed incidence of diaphragmatic dysfunction increases as more intense diagnostic modalities are applied for its detection; the incidence of diaphragm dysfunction has been recorded to be as high as 78% with sensitive methodology [1]. The fact that postoperative diaphragmatic motion abnormalities continue to be a generally acknowledged clinical problem was the motivation for our study [2].

We support use of an insulating pad when slush is used, although objective results reported in the literature have been mixed [3, 4]. Many clinicians continue to be skeptical that a two-dimensional insulating pad can restrain a liquid or semiliquid substance such as slush.

We also were of the opinion, before our study, that topical hypothermia was a significant beneficial component of myocardial protection. We were surprised to find no clinically discernible additional protective effect in our study. Doctor Weinstein’s brief presentation of his clinical data cannot speak to this point, as slush appears to have been used uniformly.

Diaphragm dysfunction, like postoperative atrial fibrillation, continues to be a vexing problem for the cardiac surgeon, contributing significantly to morbidity and costs of care [5–7].

We appreciate Dr Weinstein’s sharing of his clinical experience. His results are excellent, and his own techniques should not be altered in any way.

References

  1. DeVita M.A., Robinson L.R., Rehder J., et al. Incidence and natural history of phrenic neuropathy occurring during open heart surgery. Chest 1993;103:850-856.[Abstract/Free Full Text]
  2. Nikas D.J., Ramadan F.M., Elefteriades J.A. Topical hypothermia: ineffective and deleterious as adjunct to cardioplegia for myocardial protection. Ann Thorac Surg 1998;65:28-31.[Abstract/Free Full Text]
  3. Efthimiou J., Butler J., Woodham C., et al. Diaphragm paralysis following cardiac surgery: role of phrenic nerve cold injury. Ann Thorac Surg 1991;52:1005-1008.[Abstract]
  4. Esposito R.A., Spencer F.C. The effect of pericardial insulation on hypothermic nerve injury during open heart surgery. Ann Thorac Surg 1987;43:303-308.[Abstract]
  5. Diehl J.L., Lofaso F., Deleuze P., et al. Clinically relevant diaphragmatic dysfunction after cardiac operations. J Thorac Cardiovasc Surg 1994;107:487-498.[Abstract/Free Full Text]
  6. Werner R.A., Geiringer S.R. Bilateral phrenic nerve palsy associated with open heart surgery. Arch Phys Med Rehabil 1990;71:1000-1002.[Medline]
  7. Elefteriades J.A. The diaphragm: dysfunction and induced pacing. In: Baue A.E., Geha A.S., Hammond G.L., Laks H., Naunheim K.S., eds. Glenn’s thoracic and cardiovascular surgery, sixth ed. Stamford, CT: Appleton & Lange, 1996:623-642.




This Article
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