Diaphragm dysfunction following congenital heart surgery: Epidemiology and outcomes

Michael Ruppe; Aaron DeWitt; Kurt R Schumacher; Jeffrey P Jacobs; Claudia A Algaze; Andrew Smith; Renae Akins; Katherine Mikesell; Wenying Zhang; Erle Austin; Javier J Lasa

doi:10.1016/j.jtcvs.2026.02.024

Diaphragm dysfunction following congenital heart surgery: Epidemiology and outcomes

J Thorac Cardiovasc Surg. 2026 Feb 28:S0022-5223(26)00181-9. doi: 10.1016/j.jtcvs.2026.02.024. Online ahead of print.

Authors

Affiliations

¹ Division of Pediatric Critical Care Medicine, Norton Children's Hospital, University of Louisville, Louisville, Ky. Electronic address: michael.ruppe@louisville.edu.
² Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa.
³ Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich.
⁴ Division of Cardiovascular Surgery, University of Florida, Gainesville, Fla.
⁵ Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, Calif.
⁶ Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn.
⁷ Division of Pediatric Critical Care Medicine, Norton Children's Hospital, University of Louisville, Louisville, Ky.
⁸ PC(4) Data Coordinating Center, Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor, Mich.
⁹ Division of Cardiothoracic Surgery, Norton Children's Hospital, University of Louisville, Louisville, Ky.
¹⁰ Divisions of Cardiology and Critical Care, UT Southwestern Medical Center, Dallas, Tex.

PMID: 41765325
DOI: 10.1016/j.jtcvs.2026.02.024

Abstract

Objective: To leverage a large clinical registry of pediatric cardiac critical care patients to better understand current practices related to the diagnosis and management of patients with diaphragm dysfunction (DD) following congenital heart surgery (CHS).

Methods: Pediatric Cardiac Critical Care Consortium registry data for August 2014 to September 2022 were evaluated. Patient characteristics and hospital courses were evaluated relative to the development of DD. Date stamps described the relationship between index procedure and date of DD diagnosis, date of diaphragm plication, and outcomes. Risk factors for the development of DD were identified from patient and procedural variables via a 2-step, 2-level logistic regression with hospital random effect.

Results: Among 77,383 unique patients undergoing an index operation, 1130 patients (1.5%) were found to have DD. Of these, 510 patients (45%) underwent plication. Risk factors for DD included younger age and higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category. Patients with DD had longer mechanical ventilation duration, higher incidence of major complications, and longer cardiac intensive care unit and hospital length of stay, although the significance of this correlation is unclear given potential ascertainment bias and residual confounding. The median date of diagnosis was postoperative day 7 (interquartile range [IQR], days 4-13), and the median date of plication was postoperative day 14 (IQR, days 9-24). Patients undergoing plication did not have higher rates of major complications.

Conclusions: Patients with DD exhibit multifaceted clinical features that warrant individualized treatment considerations to optimize clinical outcomes. Neonatal age, functionally univentricular surgery, and failed extubation were found to be important triggers for pursuing a diagnosis and considering surgical plication.

Keywords: congenital heart surgery; diaphragm dysfunction; diaphragm plication; mechanical ventilation.