ARC Journal of Surgery Volume 2, Issue 2, 2016, PP 16-19 ISSN No. (Online): 2455-572X http://dx.doi.org/10.20431/2455-572X.0202004 www.arcjournals.org ©ARC Page | 16 Diaphragmatic Plication in a Mechanically Ventilated Patient with Phrenic Nerve Paralysis and Severe Pre-Operative Respiratory Insufficiency Lucia Morelli a , Enrico Ferrari a , Federico Mazza b , Massimiliano Venturino b , Mattia Manitto a , Giovanni B. Ratto a a Department of Thoracic Surgery, University San Martino Hospital and National Cancer Research Institute, Largo Rosanna Benzi 10, Genova, Italy b Department of Thoracic Surgery, Santa Corona Hospital, Pietra Ligure, Savona, Italy Abstract: Introduction: we propose the objective revision of a critical clinical case which presented so important life- threatening complications. Presentation of Case: we present a case of patient underwent cardiovascular surgery, developing diaphragmatic paralysis and dependence on mechanical ventilation. Discussion: The patient was weaned from mechanical ventilation after diaphragmatic plication, in spite of severe pre-operative respiratory insufficiency. Conclusion: This case let us re-valuate the surgical indication of diaphragmatic plication for weaning a patient from a mechanical ventilation. Keywords: phrenic nerve paralysis, diaphragmatic plication, mechanical ventilation 1. INTRODUCTION Diaphragmatic plication (DP) for phrenic nerve palsy occurring after cardiac surgery is infrequently performed in adults, despite its successful application in children [1]. Paucity of the relevant literature is one of the main barriers to the widespread adoption of DP in adult patients. In this setting, only few reports deal with DP to wean from mechanical ventilation in patients with severe respiratory insufficiency [1]. We present a case of failure to wean from mechanical ventilation, successfully treated by DP in a patient with postcardiotomy phrenic nerve paralysis and severe respiratory insufficiency. 2. MATERIALS AND METHODS A 70-year-old man was admitted with diagnosis of distal aortic arch aneurysm (8x10x8 cm) extending from the origin of left subclavian artery to the descending aorta. Cardiac ejection fraction was 60%, forced vital capacity 66%, forced expiratory volume in one second 50%, PaO2 52 mmHg and PaCO2 43 mmHg, respectively. Through a median sternotomy and left anterior thoracotomy a cardiopulmonary by-pass was instituted. A neurysmectomy, replacement of the aortic arch and proximal descending aorta (30 mm vascular graft: Intervascular; WL Gore & Associates Inc, USA) and button re implantation of the left subclavian, left common carotid and right brachiocephalic artery were carried out. Extubated on the second post-operative day (pod), the patient showed signs of left hemiplegia with brain Computed Tomography (CT) evidence of right parietal and frontal lesions. Re-intubated for a severe respiratory distress syndrome requiring mechanical ventilation, the patient showed diffuse left lung atelectasis and elevation of the left hemi-diaphragm (Figures 1a, 2a). Cardiac ultrasound demonstrated preserved cardiac function with ejection fraction of 58%. Despite tracheostomy, several attempts of mechanical ventilation weaning were unsuccessful. On the eight