Combined left-sided recurrent laryngeal and phrenic nerve palsy after coronary artery operation

Background. Ice/saline slush used along with cold cardioplegia for heart arrest in cardiac operations can cause hypothermic damage to certain structures, an important one being the left phrenic nerve, damage of which results in raised left hemidiaphragm and delayed recovery of the patient. In coronary artery bypass grafting, opening of the pleura and collection of the ice/saline slush in the pleural cavity increases the incidence of injury. Methods. Three of our nonconsecutive patients underwent coronary artery bypass grafting with cold cardioplegia and open pleura, with collection of ice/saline slush in the pleural cavity for a sufficiently long time. Results. Simultaneous involvement of left recurrent laryngeal nerve along with left phrenic nerve was found in all patients without any concurrent topical injury around the larynx. The recurrent laryngeal nerve took 8 to 10 months to recover. Conclusions. The left recurrent nerve as it arches around aorta lies in the thorax very close to the parietal pleura and may be prone to hypothermic injury by ice/slush collecting in the pleural cavity during cardiac operations. Judicious use of ice/saline slush has helped in eliminating the problem to some extent.