CTICasesBilateral Diaphragmatic Paralysis Post-Heart Transplant
Imaging findings
Chest radiographs post-transplant show persistent bilateral low lung volumes. Diaphragmatic fluoroscopy (sniff test) performed in the standing position shows seemingly preserved bilateral excursion. However, when the patient is placed in the supine position, active diaphragmatic motion disappears, and the hemidiaphragms exhibit paradoxical superior motion during inspiration.
Key takeaways
Bilateral diaphragmatic paralysis is a known complication of cardiothoracic surgeries, such as heart transplantation or LVAD placement, typically caused by intraoperative phrenic nerve traction or injury. The diagnosis can be easily missed on upright fluoroscopy because patients often utilize abdominal muscle contraction during exhalation to passively drive the diaphragm upward, mimicking active excursion upon relaxation; performing the test supine is critical to eliminate this compensatory mechanism and unmask true paralysis.
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