71 y/o male with significant cardiopulmonary comorbidities (CAD, atrial fibrillation, COPD, chronic hypoxic respiratory failure) and heavy smoking history (76.2 pack-years, quit 05/2024) underwent CABG x3 on 08/05/2024, complicated by left phrenic nerve injury resulting in left hemidiaphragm paralysis. Despite robotic diaphragmatic plication on 10/16/2024, he had only transient improvement followed by persistent, severe dyspnea and functional decline. Continued hypoxic respiratory failure from phrenic nerve palsy superimposed on underlying COPD, he had a right single lung transplant on 6/17/25 without complications.
The operative report was silent on the following:
• Identification or visualization of the phrenic nerve during LIMA harvest
• Use of or deliberate avoidance of topical ice slush / cold saline
• Any pericardial insulating pad or nerve protection technique
• Intraoperative neuromonitoring
Files:
Q: Would like detailed preop history, all three operative notes. Suspect error in protecting left phrenic during LIMA harvest, but need op notes
A: —
Do you believe there might have been medical error?
The described patient presents remarkable risk factors for postoperative respiratory failure, which was probably exacerbated by the sternotomy and the left hemidiaphragm paralysis. "Chronic hypoxic respiratory failure" seems suggestive of possible home O2 requirements, which is usually highly predictive or postoperative pulmonary complications.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
When excluding the risk factors, the lack of specific operative details makes it difficult to establish causation. Although rare, unilateral phrenic nerve injury can occur even when the listed precautions (i.e. pericardial pad, avoidance of topical ice slush, etc) are taken. Unilateral hemidiaphragm paralysis is generally tolerated if plication is performed and followed by proper physical therapy. In this case, however, the respiratory risk factors (the fact itself that the patient had indication for lung transplantation !) seems prevailing.
What makes you a good expert for this case?
Attending cardiothoracic surgeon for the past 18 years. A very large part of my practice is represented by CABG procedures.
How often do you encounter cases similar to this one in your practice?
Very rarely. Patients with significant pulmonary risk factor and chronic respiratory failure are generally directed to transcatheter percutaneous intervention.
Do you believe there might have been medical error?
Based upon my review of the materials made available to date, it is my preliminary opinion that, absent evidence of a specific intraoperative mishap, a clearly avoidable mechanism of injury, or some other material departure from accepted cardiothoracic surgical practice, I do not presently find sufficient basis to conclude that the operating surgeon breached the applicable standard of care. Phrenic nerve injury is a recognized complication of CABG surgery, particularly in cases involving LIMA harvest and myocardial cooling techniques, and the occurrence of such an injury, standing alone, is not prima facie evidence of negligence. At present, the information provided appears to establish a significant postoperative complication and substantial resulting harm, but it does not, in my opinion, establish that the surgeon failed to act in accordance with the standard of care. This opinion is necessarily preliminary and remains subject to revision should additional records, testimony, or operative details disclose evidence of a preventable injury mechanism or a deviation from accepted surgical technique.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Provided there was no preoperative elevated left hemidiaphragm, no evidence of prior left phrenic dysfunction, and no other more plausible alternative explanation, the available information is sufficient to support causation on a more-likely-than-not basis. The injury appears temporally and anatomically linked to the CABG. The extent of damages attributable to that injury, however, may still depend on the patient’s baseline pulmonary disease and preoperative pulmonary function.
What makes you a good expert for this case?
I am a good expert for this case because I have more than 25 years of experience in cardiothoracic surgery, including longstanding practice in adult cardiac surgery and extensive experience performing CABG procedures. I have held multiple leadership roles, including Medical Director, Division Chief, and Director of Advanced Heart Failure/ECMO/TAVR programs, and my background includes board certification in thoracic surgery, academic appointments, publications, and national professional involvement in the field.
How often do you encounter cases similar to this one in your practice?
I encounter postoperative diaphragmatic dysfunction after cardiac surgery with some regularity, although in most cases it is temporary and improves over time. Permanent or prolonged paralysis is much less common and is more often seen when there has been a more significant phrenic nerve insult, particularly in association with LIMA harvest, topical cold injury/myocardial cooling, reoperative surgery, dense intrathoracic adhesions that make visualization more difficult, or in patients with substantial underlying pulmonary disease.
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