Abstract:

Aim: was to establish methods of coronary artery bypass graft (CABG) with use of internal thoracic artery (ITA), that influenced high risk of continued diaphragmatic dysfunction in early post-operative period, on the base of analysis of dynamics of diaphragmatic dysfunction after operation.

Materials and methods: the retrospective study included 880 patients in the early period after CABG with use of ITA. The mobility of diaphragm domes was estimated on 2,8±0,88 day after the surgery, when transferred from the intensive care unit to the in-patient department and again on 7,7±1,9 day when transferred to the rehabilitation department. Patients were divided into 3 groups. The first group with normal diaphragm mobility with an initial study of 529(60,1%) patients. The second group with diaphragmatic dysfunction in the initial study and the restored mobility of the diaphragm in a re-examination of 249(28,3%) patients. The third group with diaphragmatic dysfunction, which persists in the re-examination of 102(11,6%) patients. The criterion for diaphragmatic dysfunction was the amplitude of the diaphragm's movement ess than 10 mm. Using the model of logistic regression, the influence of the CABG methods on the probability of maintaining diaphragmatic dysfunction at the end of the early postoperative period was determined. Two CABG methods were included in the model: «in situ» and autograft.

Results: in the primary study, 39,9% of patients had diaphragmatic dysfunction, 21,1% left-sided, 8,0% right-sided, and 10,8% bilateral. The prevalence of diaphragmatic dysfunction during the early postoperative period decreases threefold, from 39,9% to 11,5%, and was persisted more often as a unilateral lesion: left-sided in 7,2% of patients or right-sided in 3,4%, Less often, bilateral dysfunction persists in 0,9% of patients. Restoration of the function of the diaphragm during repeated examination was observed in 71,2% of cases of initial dysfunction. A different effect was established on the persistence of unilateral and bilateral diaphragmatic dysfunction by the end of the early postoperative period, depending on methods of CABG with use of ITA and their combination. High likelihood conservation diaphragmatic dysfunction by the right harvest of ITA was observed after bypass «in situ» (OR 4.4; CI 2,2-8,9) and by the harvest of ITA left after bypass graft (OR 4.1; CI 1,6-10,6). Other methods of grafting either did not have an effect on the preservation of dysfunction on the part of the ITA harvest, or the effect was traced, but was statistically insignificant.

Conclusion: dysfunction of the diaphragm acquired after CABG with use of ITA is reversible. During the early postoperative period, 71,2% of patients undergo full restoration of diaphragm mobility, the prevalence of diaphragmatic dysfunction decreases three-fold, the frequency of bilateral diaphragm dysfunction decreases by 10 times. Methods of CABG with use of ITA, «insitu» and autograft, affect the likelihood of the dysfunction of the diaphragm retained during the early postoperative period by surgical manipulation. Results of the study indicate that chances of maintaining diaphragmatic dysfunction were 4,4 times higher by grafting the right ITA «in .situ» and 4,1 times by grafting the left ITA with a graft. While the likelihood of maintaining diaphragmatic dysfunction was low by grafting the right ITA with a graft and was absent from the grafting of the left ITA «in situ».

References

1.      Paramonova T.I., Vdovkin A.V., Pal'kova V.A. Factors, influencing the development of diaphragmatic dysfunction in the early postoperative period after cardiac surgery. Diagnosticheskaya I interventsionnaya radiologia. 2016; 10(2):11-16.

2.      Canbaz S, Turgut N, Halici U, et al. Electrophysiological evaluation of phrenic nerve in-jury during cardiac surgery - a prospective, controlled, clinical study. BMC Surgery. 2004, 4:2

3.      Deng Y Byth K, Paterson HS. Phrenic nerve injury associated with high free right internal mammary artery harvesting. Ann Thorac Surg. 2003; 76(2):459-463

4.      Bazylev V.V., Paramonova T.I., Vdovkin A.V., i soavt. Ocenka faktorov, vliyayushchih na razvitie dispnoeh v rannem posleoperacionnom periode posle kardiohirurgicheskih vmeshatel'stv. [Factors affecting the development of dyspnea in the early postoperative period after cardiac surgery] Diagnosticheskaya i intervencionnaya radiologiya. 2016; 10(4):19-27.

5.      Bonacchi M, Prifti E, Giunti G, et al. Respiratory dysfunction after coronary artery bypass grafting employing bilateral internal mammary arteries: the influence of intact pleura. Eur J Cardiothorac Surg. 2001; 19:827-833.

6.      Matsumoto M., Konishi Y, Miwa S., et al. Effect of different methods of internal thoracic artery harvest on pulmonary function. Ann Thorac Surg. 1997; 63: 653-655.

7.      Uzun K, Kara H, Ugurlu D. The Effects Of Internal Mammary Artery Harvesting Techniques On Pulmonary Functions. Ko§uyolu Kalp Dergisi. 2011; 14(3):76-78.

8.      Diehl JL, Lofaso F, Deleuze P, et al. Clinically relevant diaphragmatic dysfunction after cardiac operations. J Thorac Cardiovasc Surg. 1994; 107:487-498

9.      Bazylev V.V., Paramonova T.I., Vdovkin A.V. Analiz polozheniya i podvizhnosti diafragmy u vzroslyh s normal'noj funkciej legkih do i posle kardiohirurgicheskih operacij. [Analysis of position and mobility of the diaphragm in adults with normal lung function before and after cardiac surgery.] Luchevaya diagnostika i terapiya. 2017;(1):53-63.

10.    Davison A., Mulvey D. Idiopathic diaphragmatic weakness. BMJ 1992; 304:492-494

11.    McCool F.D., McCool G.E. Dysfunction of the Diaphragm. N Engl J Med. 2012; 366:932-942

12.    Kim WY Suh HJ, Hong SB, et al. Diaphragm dysfunction assessed by ultrasonography: Influence on weaning from mechanical ventilation. Critical Care Medicine. 2011; 12:2627-2630.

13.    Bazylev V.V., Nemchenko E.V., Karnahin V.A., i soavt. Floumetricheskaya ocenka koronarnyh shuntov v usloviyah iskusstvennogo krovoobrashcheniya i na rabotayushchem serdce. [Flowmetric estimation of coronary grafts in conditions of extracorporeal circulation and on a working heart.] Angiologiya i sosudistaya hirurgiya. 2016; 22(1):67-72.

14.    Rankin JS, Tuttle RH, Wechsler AS. et al. Techniques and benefit of multiple internal mammary artery bypass at 20 year of follow up. Ann Thorac Surg. 2007; 83:1008-1015.

15.    Buxton BF, Tatoulis J, Fuller JA. The right internal thoracic artery: the forgotten conduit - 5,766 patients and 991 angiograms. The Annals of Cardiothoracic Surgery. 2011; 92: 9-17.

16.    Lytle BW, Blackstone EH, Sabik JF. et al. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg 2004;78(6):2005-2014.

17.    Tripp HF., Sees DW, Lisagor P.G, et al. Is phrenic nerve dysfunction after cardiac surgery related to internal mammary harvesting? J Card Surg. 2001, 16(3):228-231

18.    Calafiore AM, Di Giammarco G., Teodori G, et al. Bilateral internal thoracic artery grafting with and without cardiopulmonary bypass: six-year clinical outcome. J Thorac Cardiovasc Surg. 2005; 130(2):340—345.

19.    Cygel'nikov S.A. Vnutrennyaya grudnaya arteriya v hirurgicheskom lechenii ishemicheskoj bolezni serdca: varianty i taktika ispol'zovaniya, rezul'taty. [Internal thoracic artery in the surgical treatment of ischemic heart disease: options and tactics of use, results.] Avtoreferat Dis. dok. med. nauk. M., 2010; 49.

20.    Buxton BF, Ruengskulrach P, Fuller J, et al. The right internal thoracic artery graft - benefits of grafting the left coronary system and native vessels with a high-grade stenosis. The European Journal of Cardio-Thoracic Surgery. 2000; 18:255-261.

21.    Bazylev V.V., Nemchenko E.V., Pavlov A.A., i soavt. Sravnitel'nye rezul'taty revaskulyarizacii bassejna pravoj koronarnoj arterii s ispol'zovaniem bimammarnogo Y- grafta i autoveny. [Comparative results of revascularization of right coronary artery basin using bimammary Y-graft and autovein.] Grudnaya i serdechno-sosudistaya hirurgiya. 2014; 5:11-18.

22.    Vecherskij YU.YU., Andreev S.L., Zatolokin V.V. Taktika ispol'zovaniya pravoj vnutrennej grudnoj arterii «in situ» pri koronarnom shuntirovanii. [Tactics of using the right internal thoracic artery «in situ» in CABG surgery.] Angiologiya isosudistaya hirurgiya. 2015; 1(21):148-154.

23.    O'Brien JW, Johnson SH, VanSteyn SJ, et al. Effects of internal mammary artery dissection on phrenic nerve perfusion and function. Ann Thorac Surg. 1991; 52: 182-188.

24.    Sharma AD, Parmley CL, Sreeram G, et al. Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention. Anesth Analg. 2000; 91(6):1358

25.    Wilcox PG, Pardy RL. Diaphragmatic weakness and paralysis. Lung. 1989; 167:323-341

26.    Buxton BF, Hayward PA. The art of arterial revascularization - total arterial revascularization in patients with triple vessel coronary artery disease. The Annals of Cardiothoracic Surgery. 2013; 2: 543-551.

27.    Paterson HS, Naidoo R., Byth K, et al. Full myocardial revascularization with bilateral internal mammary artery Y grafts. The Annals of Cardiothoracic Surgery. 2013; 2: 444-452.

28.    Akchurin R. S., Shiryaev A. A., Brand YA. B., i soavt. Hirurgiya koronarnyh arterij - krajnosti i algoritmy revaskulyarizacii. [Surgery of coronary arteries - extremes and algorithms of revascularization.] Grudnaya i serdechno-sosudistaya hirurgiya. 2001; 2:13-17

Abstract:

Aim: was to assess chances of the development of postoperative diaphragmatic dysfunction (DD), depending on methods of coronary artery bypass graft (CABG), by estimation the probability of development of DD according to the side of internal thoracic artery (ITA) harvest.

Materials and methods: evaluation of the mobility of domes of the diaphragm in the early perioc after 3051 CABG operations (with use of ITA) was made. Control group included patients with normal mobility of the diaphragm. Study group included patients with right-sided, left-sided and bilateral DD. Using a logistic regression model we evaluated the influence of the method of CABG (with use of ITA) in the development of DD from the side of the ITA harvest. The model included two ways of CABG - «in situ» and autograft.

Results: there are differences in chances of development of unilateral and bilateral DD, depending on the method of CABG (with use of ITA) and combinations thereof. High possibility of developing DD after CABG with right ITA was observed after CABG «in situ» (OR 5,4; CI 4,3-6,8), and smaller after CABG with ITA autograft (OR 1,8; CI 1,4-2,3). High possibility of DD was observed after CABG with left ITA autograft (OR 3,5; CI 2,2-5,6); after CABG «in situ», there was no DD.

Conclusion: methods of CABG using ITA, «in situ» and autograft, differently affect the mobility of the diaphragm from the side of surgical procedure. Results of the study indicate a high probability of DD after CABG with left ITA autograft and right ITA «in situ». It is established that possibility of DD was low in case of CABG with right ITA as autograft and was absent in left ITA «in situ».

References

1.      Bazylev V.V., Paramonova T.I., Vdovkin A.V. Analysis of position and mobility of the diaphragm in adults with normal lung function before and after cardiac surgery. Luchevaya diagnostika i terapiya. 2017;(1):53-63. [In Russ].

2.      Paramonova T.I., Vdovkin A.V., Pal'kova V.A. Factors, influencing the development of diaphragmatic dysfunction in the early postoperative period after cardiac surgery. Diagnosticheskaya i intervencionnaya radiologiya. 2016; 10(2):11-16. [In Russ].

3.      Canbaz S., Turgut N., Halici U., et al. Electrophysiological evaluation of phrenic nerve injury during cardiac surgery - a prospective, controlled, clinical study. BMC Surgery. 2004, 4:2

4.      Deng Y, Byth K., Paterson H.S. Phrenic nerve injury associated with high free right internal mammary artery harvesting. Ann Thorac Surg. 2003; 76(2):459-463.

5.      Bazylev V.V., Paramonova T.I., Vdovkin A.V., et al. Factors affecting the development of dyspnea in the early postoperative period after cardiac surgery. Diagnosticheskaya i intervencionnaya radiologiya. 2016; 10(4):19-27. [In Russ].

6.      Bonacchi M, Prifti E, Giunti G, et al. Respiratory dysfunction after coronary artery bypass grafting employing bilateral internal mammary arteries: the influence of intact pleura. Eur J Cardiothorac Surg. 2001; 19:827-833.

7.      Matsumoto M., Konishi Y, Miwa S., et al. Effect of different methods of internal thoracic artery harvest on pulmonary function. Ann Thorac Surg. 1997; 63:653-655.

8.      Uzun K., Kara H., Ugurlu D. The Effects Of Internal Mammary Artery Harvesting Techniques On Pulmonary Functions. Ko§uyolu Kalp Dergisi. 2011; 14(3):76-78.

9.      Ozkara A., Hatemi A., Mert M.,et al.The effects of internal thoracic artery preparation with intact pleura on respiratory function and patients' early outcomes. Anadolu Kardiyol Derg. 2008; 8: 368-373.

10.    Bazylev V.V., Nemchenko E.V., Karnahin V.A.. et al. Flowmetric estimation of coronary bypass grafts in conditions of extracorporeal circulation and on a working heart.] Angiologiya i sosudistaya hirurgiya. 2016;22(1): 67-72. [In Russ].

11.    Rankin J.S., Tuttle R.H., Wechsler A.S. et al. Techniques and benefit of multiple internal mammary artery bypass at 20 year of follow up. Ann Thorac Surg. 2007; 83:1008-1015.

12.    Buxton B.F., Tatoulis J., Fuller J.A. The right internal thoracic artery: the forgotten conduit - 5,766 patients and 991 angiograms. The Annals of Cardiothoracic Surgery. 2011; 92: 9-17.

13.    Lytle B.W., Blackstone E.H., Sabik J.F. et al. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg 2004;78(6):2005-2014

14.    Tatoulis J. Total arterial coronary revascularization - patient selection, stenoses, conduits, targets. The Annals Cardiothoracic Surgery. 2013;2:499-506.

15.    O'Brien J.W., Johnson S.H., VanSteyn S.J., et al. Effects of internal mammary artery dissection on phrenic nerve perfusion and function. Ann Thorac Surg. 1991; 52: 182-188.

16.    Sharma A.D., Parmley C.L., Sreeram G., et al. Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention. Anesth Analg. 2000; 91(6):1358

17.    Calafiore A.M., Di Giammarco G., Teodori G., et al. Bilateral internal thoracic artery grafting with and without cardiopulmonary bypass: six-year clinical outcome. J Thorac Cardiovasc Surg. 2005; 130(2):340-345.

18.    Cygel'nikov S.A. Internal thoracic artery in the surgical treatment of ischemic heart disease: options and tactics of use, results. Avtoreferat Dis. dok. med. nauk. M., 2010; 49. [In Russ].

19.    Buxton B.F., Ruengskulrach P., Fuller J., et al. The right internal thoracic artery graft - benefits of grafting the left coronary system and native vessels with a high-grade stenosis. The European Journal of Cardio-Thoracic Surgery. 2000; 18: 255-261.

20.    Bazylev V.V., Nemchenko E.V., Pavlov A.A., et al. Comparative results of revascularization of right coronary artery basin using bimammary Y-graft and autovein. Grudnaya i serdechno-sosudistaya hirurgiya. 2014; 5: 11-18. [In Russ].

21.    Vecherskij YU.YU., Andreev S.L., Zatolokin V.V. Tactics of using the right internal thoracic artery «in situ» in CABG surgery.] Angiologiya i sosudistaya hirurgiya. 2015;1(21):148-154. [In Russ].

22.    Buxton B.F., HaywardPA. The art of arterial revascularization - total arterial revascularization in patients with triple vessel coronary artery disease. The Annals of Cardio-thoracic Surgery. 2013;2:543-551.

23.    Paterson H.S., Naidoo R., Byth K., et al. Full myocardial revascularization with bilateral internal mammary artery Y grafts. The Annals of Cardiothoracic Surgery. 2013;2:444-452.

24.    Akchurin R. S., Shiryaev A. A., Brand YA. B., et al. Surgery of coronary arteries - extremes and algorithms of revascularization. Grudnaya i serdechno-sosudistaya hirurgiya. 2001; 2:13-17. [In Russ]. 

Abstract:

Aim: was to reveal factors, influencing high cnance of dysfuntion of diaphragm domes in further patient examination by estimation of dynamics of acqired diaphragmatic dysfunction after different cardiac surgical interventions.

Material and methods: research included 642 patients after different cardiac surgical interventions. We estimated mobility of diaphragm domes at the moment of patients discharge from intensive care unit and secondly before transporting to rehabilitation center. All patients were devided into 3 groups. 1st group: patients with normal mobility of diaphragm at initial examination - 395 (61,5%). 2nd group - diaphragmatic dysfunction at initial examination and recovered mobility at further examination - 173 patients (26,9%). 3rd group - patients with diaphragmatic dysfunction at both stages of examination - 74 (11,5%). Criteria for diaphragmatic dysfunction - mobility amplitude of domes less than 10 mm. We estimated chances of extant dysfunction, under the influence of complex of clinical and surgical factors.

Results: at initial examination diaphragmatic dysfunction was revealed at 38,5%, left dome - 18,2%, right dome - 10,3%, bilateral dysfunction - 10,0%. At further examination diaphragmatic dysfunction persisted in 11,5% of patients, left-sided - 7,5%, right-sided - 3,9%, bilateral - in one case. Recovery of diaphragmatic function was achieved in 70% of initial dysfunction. High and statistically significant chances of extant dysfunction were evaluated only in case of unilateral separation of internal thoracic artery (ITA). Other surgical and clinical factors had no statistically sugnificant influence.

Conclusions: aquired diaphragmatic dysfunction after different cardiac surgical interventions ir 70% of cases is reversible. Recovery of diaphragm mobility was full. Prevalence of diaphragmatic dysfunction decreases for 5 days from 38,5% to 11,5% and persists usually unilateral: left-sided - 7,5%, right-sided - 3,9%.

The only statistically significant surgical factor, influencing high risk of appearance and extantion of post-operative domes dysfunction is unilateral separation of ITA. 

References

1.    Bazylev V.V., Paramonova T.I., Vdovkin A.V. Ocenka faktorov, vlijajushhih na razvitie dispnoje v rannem posleoperacionnom periode posle kardiohirurgicheskih vmeshatel'stv. [Factors affecting the development of dyspnea in the early postoperative period after cardiac surgery.] Diagnosticheskaja i intervencionnaja radiologija. 2016;10(4):19-27 [In Russ].

2.    Davison A., Mulvey D. Idiopathic diaphragmatic weakness. BMJ 1992; 304:492-494.

3.    McCool F.D., McCool G.E. Dysfunction of the Diaphragm. N Engl J Med. 2012; 366:932-942.

4.    Canbaz S., Turgut N., Halici U., et al. Electrophysiological evaluation of phrenic nerve injury during cardiac surgery - a prospective, controlled, clinical study. BMC Surgery. 2004, 4:1-5.

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.

6.    McCool F.D., Mead J. Dyspnea on immersion: mechanisms in patients with bilateral diaphragm paralysis. Am Rev Respir Dis. 1989; 139:275-276.

7.    Steier J., Jolley C.J., Seymour J., et al. Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness. Eur Respir J. 2008; 32:1479-1487.

8.    Kim W.Y, Suh H.J., Hong S.B., et al. Diaphragm dysfunction assessed by ultrasonography: Influence on weaning from mechanical ventilation. Critical Care Medicine. 2011;12:2627-2630.

9.    Deng Y, Byth K., Paterson H.S. Phrenic nerve injury associated with high free right internal mammary artery harvesting. Ann Thorac Surg. 2003; 76(2):459-463.

10.  Mazzoni M., Solinas C., Sisillo E., et al. Intraoperative phrenic nerve monitoring in cardiac surgery. Chest. 1996; 109(6):1455-1460.

11.  Tripp H.F., Sees D.W., Lisagor P.G., et al. Is phrenic nerve dysfunction after cardiac surgery related to internal mammary harvesting? J Card Surg. 2001; 16(3): 228-231.

12.  Metzner A., Rausch P., Lemes C., et al. The incidence of phrenic nerve injury during pulmonary vein isolation using the second-generation 28 mm cryoballoon. J Cardiovasc Electrophysiol. 2014; 25(5):466-470.

13.  Merino-Ramirez M.A., Juan G., Rair^n M., et al. Electrophysiologic evaluation of phrenic nerve and diaphragm function after coronary bypass surgery: prospective study of diabetes and other risk factors. J Thorac Cardiovasc Surg. 2006; 132:530-536.

14.  Paramonova T.I., Vdovkin A.V. Faktory, vlijajushhie na razvitie diafragmal'noj disfunkcii v rannem posleoperacionnom periode posle kardiohirurgicheskih vmeshatel'stv [Factors, influencing the development of diaphragmatic dysfunction in the early postoperative period after cardiac surgery.] Diagnosticheskaja i intervencionnaja radiologija. 2016; 10(2): 11-16 [In Russ].

15.  Chetta A., Rehman A.K., Moxham J., et al. Chest radiography cannot predict diaphragm function. Respir. Med. 2005; 99:39-44.

16.  O'Brien J.W., Johnson S.H., VanSteyn S.J., et al. Effects of internal mammary artery dissection on phrenic nerve perfusion and function. Ann Thorac Surg. 1991; 52: 182-8

17.  Sharma A.D., Parmley C.L., Sreeram G., et al. Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention. Anesth Analg. 2000; 91(6):13

Abstract:

Aim: was to evaluate the influence of factors on the development of diaphragmatic dysfunction ir early periods after cardiac surgery

Materials and methods: study included 830 patients after various cardiac surgery in Federal National Center of Cardiovascular Surgery (Penza, Russian Federation). In the early postoperative period (3,9 ± 0,9 days) all patients underwent chest x-ray while transporting from intensive care unit. We evaluated differences between diaphragm contors in two consecutive shots - with a deep breath and exhale fully In the early postoperative period diaphragmatic dysfunction was detected in 172 cases (20.7%). Patients were divided into 4 groups depending on the presence or absence of a violation of the diaphragm function. The criterion of selection into the group with diaphragmatic dysfunction was size of amplitude motion, less than 10 mm. 1st group with normal mobility of the diaphragm included 658 patients (79.3%). 2nd group with dysfunction of the left dome of the diaphragm - 85 patients(10.2%). 3rd group with dysfunction of the right dome - 58 patients (7%). 4th group with bilateral diaphragmatic dysfunction - 29 patients (3.5%). Logistic regression model included 4 variables, the significance of which is reflected by the published data: preparation of internal thoracic artery (ITA) for graft, valve surgery, the use of radiofrequency ablation, the use of cardiopulmonary bypass. We made a multiple logistic regressive analysis of predictors for the development of diaphragmatic dysfunction.

Results: we have found that under the influence of complex predictors, greatest chance of dysfunction was observed in the group with bilateral violation of diaphragm mobility after two-sidec separation of ITA (OR 3.4; CI 1.60, 7.25). High chances of dysfunction were observed in groups with unilateral violation of diaphragm mobility after unilateral separation of ITA. Separation of left ITA had higher chances for diaphragmal dysfunction (OR 2.7; CI 1.36; 5.37) than in case of separation of right ITA (OR 2.0; CI 1.16, 3.47). After valve operations, radiofrequency ablation, and cardiopulmonary bypass chances of diaphragmatic dysfunction was statistically insignificant (p>0.05) in all study groups.

Conclusions: diaphragmatic dysfunction develops in 3.4 times greater in case of bilateral separation of ITA. Unilateral dysfunction of the diaphragm has a great chance in case of separation of ITA: left up to 2.7 times and right up to 2 times. Influence of cardiopulmonary bypass, valve operations and radiofrequency ablation for the development of diaphragmatic dysfunction is statistically insignificant.

References

1.     Berrizbeitia L.D., Tessler S., Jacobowitz I.J., et al. Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics. Chest. 1989, 96(4):873-876.

2.     Deng Y, Byth K., Paterson H.S. Phrenic nerve injury associated with high free right internal mammary artery harvesting. Ann. Thorac. Surg. 2003; 76(2):459-463.

3.     Mazzoni M., Solinas C., Sisillo E., et al. Intraoperative phrenic nerve monitoring in cardiac surgery. Chest. 1996, 109(6):1455-1460.

4.     O'Brien J.W., Johnson S.H., VanSteyn S.J., et al. Effects of internal mammary artery dissection on phrenic nerve perfusion and function. Ann.Thorac. Surg. 1991, 52(2):182-188.

5.     Tripp H.F., Sees D.W., Lisagor P.G., et al. Is phrenic nerve dysfunction after cardiac surgery related to internal mammary harvesting? J. Card. Surg. 2001, 16(3): 228-231.

6.     Canbaz S., Turgut N., Halici U., et al. Electrophysiological evaluation of phrenic nerve injury during cardiac surgery - a prospective, controlled, clinical study. BMC Surgery. 2004, 4:2.

7.     Merino-Ramirez M.A., Juan G., Rair^n M., et al. Electrophysiologic evaluation of phrenic nerve and diaphragm function after coronary bypass surgery: prospective study of diabetes and other risk factors. J. Thorac. Cardiovasc. Surg. 2006; 132:530-536.

8.     Metzner A., Rausch P, Lemes C., et al. The incidence of phrenic nerve injury during pulmonary vein isolation using the second-generation 28 mm cryoballoon. J. Cardiovasc. Electrophysiol. 2014; 25(5):466-470.

9.     Diehl J.L., Lofaso F., Deleuze P, et al. Clinically relevant diaphragmatic dysfunction after cardiac operations. J. Thorac. Cardiovasc. Surg. 1994; 107:487-498.

10.   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.

11.   Smith B.M., Ezeokoli N.J., Kipps A.K., et al. Course, Predictors of Diaphragm Recovery After Phrenic Nerve Injury During Pediatric Cardiac Surgery. Ann. Thorac. Surg. 2013; 96:938-42.

12.   Kim W. Y; Suh H. J.; Hong S.-B.; Koh Y; Lim C.-M. Diaphragm dysfunction assessed by ultrasonography: Influence on weaning from mechanical ventilation. Critical Care Medicine. 2011; 12:2627-2630.

13.   Davison A., Mulvey D. Idiopathic diaphragmatic weakness. BMJ. 1992; 304:492-494.

14.   McCool F.D., Tzelepis G.E. Dysfunction of the Diaphragm. N. Engl. J. Med. 2012; 366:932-942.

15.   McCool F.D., Mead J. Dyspnea on immersion: mechanisms in patients with bilateral dia-phragm paralysis. Am. Rev. Respir Dis. 1989; 139:275-276.

16.   Steier J., Jolley C.J., Seymour J., et al. Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness. Eur. Respir. J. 2008; 32:1479-1487.

17.   Wang C.S., Josenhaus W.T. Contribution of the diaphragmatic-abdominal displacement to ventilation in supine man. J. Appl. Physiol. 1971; 31:576-80.

18.   Stradling J.R., Warley A.R. Bilateral diaphragm paralysis and sleep apnoea without diurnal respiratory failure. Thorax. 1988; 43:75-77

19.   Summerhill E.M., El-Sameed YA., Glidden T.J. Monitoring recovery from diaphragm paralysis with ultrasound. Chest. 2008; 133:737-743.

20.   El-Sobkey S.B., Salem N.A. Can lung volumes and capacities be used as an outcome measure for phrenic nerve recovery after cardiac surgeries? J. Saudi. Heart Assoc. 2011; 23:23-30.

21.   Laroche C.M., Mier A.K., Moxham J., Green M. Diaphragm strength in patients with recent hemidiaphragm paralysis. Thorax. 1988; 43:170-174.

22.   Линденбратен Л.Д. Лучевая диагностика поражений диафрагмы. Радиология и практика. 2001; 2:6-21. Lindenbraten L.D. Luchevaja diagnostika porazhenij diafragmy[Beam diagnostics of diaphragm lesions]. Radiologija ipraktika. 2001; 2:6-21[In Russ].

23.     Suwatanapongched T., Gierada D.S., Slone R.M. et al. Variation in Diaphragm Position and Shape in Adults With Normal Pulmonary Function. Chest. 2003; 123(6): 2019-2027. 

Abstract:

Aim: was to reveal factors that cause dyspnea in the early postoperative period after cardiac surgery.

Materials and methods: the study included 818 patients after cardiosurgical interventions in «F^S» Penza from June 2014 to February 2015, with complaints of shortness of breath at rest. The degree of influence of variables was determined using ROC analysis and logistic regression analysis.

Results: dyspnea was noted in 169 patients (19.4 %). ROC-analysis revealed a very large influence on the occurrence of dyspnoea disturbances of the mobility of the diaphragm, the great influence of the frequency of respiratory movements, the average impact of the height of diaphragm domes and low impact of body mass index. Results of logistic regression analysis showed that odds increase in 327 times at a decreased mobility of the left dome of the diaphragm 49 times in dysfunction of the right dome, 4,4-times elevation in the left dome, 3,5 times at the elevation of the right dome, 3.9 times with tachypnea and 2,6 times for severe obesity, in 1,5 times in chronic heart failure II B degree. Other factors, included in research, didn't influence on dispnea appearance.

Conclusions: a leading factor in the occurrence of dyspnea is dysfunction of the diaphragm, especially when decreased mobility of the left dome. To a lesser extent, reasons can be the elevation of diaphragm domes and tachypnea. Obesity 2 and 3 degree and chronic heart failure II B degree, had a small effect on dyspnea.

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