DIAPHRAM SPASMS AFTER OPEN HEART SURGERY

[Baba1040]

My otherwise healthy husband had open heart surgery last week to replace a calcified bicuspid valve and ascending aorta which had an aneurysm.  Surgery went well but when we arrived home he began suffering from spasms in his diaphram.  This is constant and often severe.  Neither his excellent, experienced surgeon, nor any of his other doctors, had heard of this and are attempting ot control it with muscle relaxers (which doesn't seem to help much).  Has anyone else suffered this and, if so, how was it treated, how long did it last, etc?  He is miserable now.

[eelnyc]

I had aortic valve replacement two weeks ago, was in the hospital 4 days and everything went great.  Over the past week my breathing has gotten labored, like I am having lung spasms.  Especially when I talk it is as if I cannot get a full breath to complete a word or sentence.

I do not have any pain, but my breathing gets better if I take percasets.  Now I am taking about 4 a day, and when I take the pill my breathing gets much better for about 3 hours.

Any ideas!

[ed34]

I have to say, fantastic post there.

[skydnsr]

Damage to the phrenic nerve, which controls the diaphragm, is not unheard of as a complication of OHS.  It happens in a small percentage (I think I've read 3%) of cases, especially cases in which the procedure was complicated and therefore prolonged.  Your husband had two major procedures, the valve replacement and the aneurysm repair, so that makes his operation complicated, by definition.  You might check the surgeon's operative report to see how long your husband was on the heart-lung bypass machine.  I'm not a doctor, so take this for what it is worth, but I'm thinking that anything over about 30 minutes would put a person at risk for phrenic nerve damage -- not that it would definitely happen, but the longer the time on the machine, the greater the risk.

Actually, you have two phrenic nerves,a left one and a right one.  The left one goes to the left half of your diaphragm, and the right one goes to the right half of your diaphragm.  These are the two nerves that trigger your diaphragm to contract, and when your diaphragm contracts, that's when you take a breath.  When one of your phrenic nerves is damaged in OHS, it is usually the left one.  The usual cause is prolonged exposure to the cold substance that the surgeon uses to stop your heart.  Rarely do both phrenic nerves get injured.  Usually it is only the one.  (When both of them do get injured, the patient usually has difficulty breathing at all, and you didn't mention that in describing your husband's symptoms, so I take it that he can still breath well enough to maintain.)  The damage can be either temporary or permanent.

Most times when a phrenic nerve is damaged, the affected half of the diaphragm will be paralyzed, either temporarily or permanently.  This is the first time I have heard of diaphragmatic spasms.  The fact that the diagphragm is spasming may be a good sign.  It may mean that the damage was relatively slight and that your husband will have a full recovery.  Even under those circumstances, the recovery could take a long time (months to years), though.  Nerves regenerate very slowly.  

There is a test called the sniff test that might or might not be helpful.  It is kind of a flouroscope-type test, where a radiologist (and sometimes the patient) can actually see the diaphragm moving in real time on a monitor.  It can show paralysis of a hemidiaphragm; I'm not sure what it can reveal in a case of spasms.  If the problem were to occur during the test, I'm thinking it can show whether it is only half of the diaphragm that is spasming -- which would pretty much nail the phrenic nerve as the culprit.  I guess the information value of the sniff test for your husband would depend on how often the spasms occur.  If they are happening with every breath, I'd say insist on the test.  If they happen only a few times a day, then chances are they would not occur while he was on the table for the test.  If it is within his control to do something to trigger them at will, then he could trigger them during the test and see what happens.

Since your husband's surgeon seems mystified, you might consider getting a second opinion, perhaps from a pulmonologist.  This isn't exactly a lung problem, but any pulmonologist should be familiar with the neuromuscular mechanism of respiration and how to troubleshoot diaphragmatic spasms.

If you were to ask your husband's surgeon some specific questions, like how long your husband was on the bypass machine, does the surgeon want to consider ordering a sniff test to see if this problem could be from phrenic nerve damage, and should your husband consult with a pulmonologist, I wonder what would happen.  

The reason I know about all of this is because I had a damaged left phrenic nerve and a paralyzed left hemi-diaphragm.  I did have a sniff test, and I'm glad I did.  It eased my mind, and it also showed my doctor that I was not a hypochondriac.  When the problem was finally diagnosed, the doctors told me that the damage would be permanent, but after a few years, I seem to have recovered.