Thoracotomy Diaphragmatic Plication for Postoperative Phrenic Nerve Palsy in a Neonate Following Repair of Tetralogy of Fallot

Diaphragmatic paralysis following congenital cardiac surgery is an important cause of postoperative respiratory morbidity in neonates and infants. Prompt recognition and appropriate management are essential to reduce ventilator dependence and improve clinical outcomes.

Case Presentation

A 23-day-old male infant underwent complete repair of tetralogy of Fallot with double outlet right ventricle on May 25, 2026. The procedure included ventricular septal defect patch closure using glutaraldehyde-treated autologous pericardium, resection of infundibular muscle bundles, and right ventricular outflow tract augmentation. The patient subsequently required delayed sternal closure, which was performed on May 28, 2026.

During the postoperative period, persistent elevation of the left hemidiaphragm was noted on chest radiography. Diaphragmatic ultrasonography demonstrated markedly reduced excursion of the left hemidiaphragm, consistent with diaphragmatic paresis, without paradoxical motion. On postoperative day 15, the patient remained on continuous positive airway pressure (CPAP) at +8 cm H₂O.

Operative Technique

Left diaphragmatic plication was performed on June 9, 2026, through a left lateral thoracotomy. Because the sternum had already been closed following delayed sternal closure and the pathology was localized to the left hemidiaphragm, a left lateral thoracotomy was selected to provide direct and focused exposure of the affected hemidiaphragm while avoiding reopening the recently closed median sternotomy.

Intraoperative findings demonstrated an elevated, flaccid left hemidiaphragm without evidence of a diaphragmatic defect or other intrathoracic pathology. The diaphragm was progressively plicated using interrupted non-absorbable Prolene sutures to restore diaphragmatic tension and improve pulmonary mechanics, while avoiding injury to adjacent thoracic structures.

Outcome

Postoperatively, the patient demonstrated radiographic improvement in diaphragmatic position and progressive respiratory recovery. He was successfully extubated to CPAP, gradually weaned from respiratory support, and maintained stable gas exchange and hemodynamics. Serial imaging supported a satisfactory postoperative recovery, and chest tube removal and CPAP discontinuation were achieved without major complications.

Conclusion

Early recognition of postoperative diaphragmatic paralysis and timely diaphragmatic plication can significantly improve respiratory function in neonates following congenital cardiac surgery. A left lateral thoracotomy provides direct exposure of an affected left hemidiaphragm and can avoid reopening a recently closed median sternotomy. This case highlights the importance of multidisciplinary postoperative surveillance and individualized surgical decision-making in managing phrenic nerve dysfunction after congenital heart surgery.

References 

1. Groth SS, Andrade RS. Diaphragm plication for eventration or paralysis: a review of the literature. Ann Thorac Surg. 2010;89(6):S2146-S2150.
2. Versteegh MI, Braun J, Voigt PG, et al. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and quality of life. Eur J Cardiothorac Surg. 2007;32(3):449-456.
3. Akay TH, Ozkan S, Gultekin B, et al. Diaphragmatic plication after phrenic nerve injury following cardiac surgery in children. Ann Thorac Surg. 2006;81(2):690-693.
4. De Vries TS, Koens BL, Vos A. Surgical treatment of diaphragmatic paralysis in children. Eur J Pediatr Surg. 1998;8(4):206-208.
5. Kokatnur L, Rudrappa M. Diaphragmatic Palsy. Diseases. 2018;6(1):16.

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