Effects of internal mammary artery dissection on phrenic nerve perfusion and function

doi:10.1016/0003-4975(91)91334-R

The Annals of Thoracic Surgery

Volume 52, Issue 2, August 1991, Pages 182-188

https://doi.org/10.1016/0003-4975(91)91334-R Get rights and content

Abstract

The effects of left internal mammary artery (LIMA) dissection and distal division on phrenic nerve perfusion and function were examined in an adult swine model. Phrenic nerve perfusion was determined by left atrial injection of radioactively labeled microspheres. Phrenic nerve function was determined by measuring nerve and diaphragm potentials evoked by bilateral phrenic nerve stimulation. In the first group of animals (n = 9), the LIMA was dissected with ligation of all its branches. Left phrenic nerve perfusion and function decreased after LIMA dissection in every animal studied, whereas only minimal changes were observed on the right. Sixty minutes after LIMA dissection, left phrenic nerve mean perfusion decreased 71%. Left phrenic nerve and left diaphragm mean action potential amplitudes decreased 54% and 80%, respectively. In the second group of animals (n = 4), the LIMA dissection was performed without division of the pericardiacophrenic artery, a small proximal branch of the internal mammary artery that supplies the phrenic nerve. Sixty minutes after LIMA dissection, left phrenic nerve perfusion had decreased by 21% from control values, with a corresponding decrease in left phrenic nerve and diaphragm mean action potential amplitudes of 19% and 23%, respectively. These results indicate that LIMA dissection with division of all its branches in this model is associated with a significant impairment in left phrenic nerve perfusion and function and suggests a causal relationship. These results may also explain the apparent increased phrenic nerve cold sensitivity and increased incidence of phrenic nerve dysfunction associated with LIMA grafting. Compared with the universally advocated method of complete LIMA dissection, sparing the pericardiacophrenic artery during the LIMA dissection significantly improves left phrenic nerve perfusion and function.

References (31)

JJ Curtis et al.
Elevated hemidiaphragm after cardiac operations: incidence, prognosis, and relationship to the use of topical ice slush
Ann Thorac Surg
(1989)
RA Esposito et al.
The effect of pericardial insulation on hypothermic phrenic nerve injury during open-heart surgery
Ann Thorac Surg
(1987)
WE Wheeler et al.
Etiology and prevention of topical cardiac hypothermia-induced phrenic nerve injury and left lower lobe atelectasis during cardiac surgery
Chest
(1985)
DL Galbut et al.
Twelve-year experience with bilateral internal mammary artery grafts
Ann Thorac Surg
(1985)
F Robicsek et al.
Biological thresholds of cold-induced phrenic nerve injury
J Thorac Cardiovasc Surg
(1990)
JD Marco et al.
Topical cardiac hypothermia and phrenic nerve injury
Ann Thorac Surg
(1977)
JA Rousou et al.
Phrenic nerve paresis associated with the use of iced slush and the cooling jacket for topical hypothermia
J Thorac Cardiovasc Surg
(1985)
DG Nichols et al.
Correlation of left phrenic arterial flow with regional diaphragmatic blood flow
J Appl Physiol
(1988)
PG Wilcox et al.
Recovery after unilateral phrenic injury associated with coronary artery revascularization
Chest
(1990)
D Hurlbut et al.
Pleuropulmonary morbidity: internal thoracic artery versus saphenous vein graft
Ann Thorac Surg
(1990)

AJ Pelias et al.

A case of postoperative internal mammary steal

J Thorac Cardiovasc Surg

(1985)

RN Singh et al.

Internal mammary graft: improved flow resulting from correction of steal phenomenon

J Thorac Cardiovasc Surg

(1982)

R Tartini et al.

Anomalous origin of the left thyrocervical trunk as a cause of residual pain after myocardial revascularization with internal mammary artery

Ann Thorac Surg

(1985)

AD Slater et al.

Extended use of bilateral internal mammary arteries for coronary artery disease

Ann Thorac Surg

(1990)

C Bakay et al.

Combined internal mammary artery graft for coronary artery revascularization

Ann Thorac Surg

(1990)

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^☆: Presented at the Twenty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 18–20, 1991.

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Original articleEffects of internal mammary artery dissection on phrenic nerve perfusion and function☆

Abstract

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Appl Physiol

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Original article
Effects of internal mammary artery dissection on phrenic nerve perfusion and function☆