Letters to the Editor Post cardiac surgery diaphragmatic spasm successfully treated with gabapentin Roberto Spoladore a , Dina Garroni d , Gabriele Fragasso a, * , Altin Palloshi a , Stefano Amadio b , Chiara Montano a , Angelo Corti c , Alberto Margonato a a Unita ` di Cardiologia Clinica, Istituto Scientifico San Raffaele, via Olgettina 60, 20132, Milano, Italy b Department of Neurology, Istituto Scientifico, Universita’ Vita, Salute San Raffaele, Milano, Italy c Department of Biochemistry, Istituto Scientifico, Universita’ Vita, Salute San Raffaele, Milano, Italy d Department of Neuroscience, Istituti Clinici di Perfezionamento, Milano, Italy Received 6 April 2005; accepted 8 May 2005 Available online 9 June 2005 Abstract We describe the case of an 82 year old woman developing severe respiratory functional impairment after open heart surgery and subsequent surgical pericardial drainage inducing diaphragmatic spasm and successfully treated with gabapentin. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Diaphragmatic spasm; Gabapentin; Cardiac surgery 1. Case report We describe the case of an 82 year old hypertensive woman under chronic steroidal therapy for long lasting asthma. In 2001, the patient was diagnosed to have severe aortic stenosis and, subsequently, she underwent aortic valve replacement with a biologic prosthesis and surgical coronary revascularization. On the 3rd post-operative day she developed cardiac tamponade, treated with surgical pericardial drainage. She was discharged in fair clinical condition on the 10th post-surgical day. Echocardiography showed normally functioning prosthetic valve and normal systolic left ventricular function. However, since then the patient had been complaining worsening dyspnoea, partially attenuated by leaning the trunk over the abdomen in search of what the patient defined as ‘‘a liberatory decontraction.’’ At a 1 year follow-up examination the patient reported worsening functional capacity and a very low quality of life. Echocardiography showed an ejection fraction of 54%, pulmonary artery pressure of 40 mmHg and moderate mitral regurgitation. Exercise testing was negative at low work- load. At a 6 min walking test, the patient walked 120 m and oxygen saturation decreased from 98% to 82%. Lung function tests evidenced total lung capacity (TLC) of 3.15 L. Diaphragmatic electromyography did not evidence any spontaneous activity. During a 10 min observation time (during which the patient became symptomatic for dysp- noea) no alterations of diaphragmatic muscle unit potential recruitment were observed. When the patient reported the sensation of a ‘‘liberatory decontraction’’ during an inspir- atory act and leaning over the trunk, an accessory forced diaphragmatic contraction of less than a second duration was observed. Carbamazepin was prescribed up to 200 mg bid. After one month of therapy, the drug was discontinued because of lack of benefit and the occurrence of somno- lence, dizziness and weakness. At this point gabapentin, progressively titrated from 100 to 300 mg tid, was prescribed. After 10 days from therapy initiation, the patient referred the disappearance of the ‘‘diaphragmatic impedi- ment.’’ However, a certain degree of tolerance was observed after the first month, determining a progressive increase of the dosage. After 6 months she was fairly well at 300 mg 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.05.003 * Corresponding author. Tel.: +39 02 26437366; fax: +39 02 26437395. E-mail address: gabriele.fragasso@hsr.it (G. Fragasso). International Journal of Cardiology 109 (2006) 282 – 283 www.elsevier.com/locate/ijcard