Iatrogenic Vocal Cord Paralysis after Cardiac Surgery: Evocative Note for Surgeon and Anesthesiologist

© 2017 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer Medknow The Editor, A 45‐year‐old female patient presented with the shortness of breath on mild exertion and palpitation for 6 months. Patient’s echocardiographic examination revealed severe mitral stenosis with enlarged left atrium. The patient was also found to have severe tricuspid regurgitation with moderate pulmonary hypertension. There was no history suggestive of voice change or hoarseness in the past. The patient was scheduled for mitral valve replacement and tricuspid annuloplasty with maze procedure for chronic atrial fibrillation (AF). Anesthesia was induced without any incident. Laryngoscopic examination showed Cormack and Lehane grade 1 glottic view. Trachea was intubated with 7.5 mm endotracheal tube with cuff (Portex® Profile Soft Seal® Cuff Tracheal Tubes from Smiths Medical). Intubation was smooth, atraumatic and in single attempt. Hypothermic cardiopulmonary bypass was established using aortic and bicaval cannulation. Heart was arrested using antegrade cold blood cardioplegia. Mitral valve was replaced with 27/29 mm. On‐X mitral valve prosthesis along with tricuspid ring annuloplasty was performed using 26 mm Edwards MC3 tricuspid annuloplasty ring and pulmonary vein isolation on both left and right sides with bipolar radiofrequency ablation was done. Total surgical duration was 220 min and cardiopulmonary bypass time was 152 min. Patient was smoothly weaned off cardiopulmonary bypass and was shifted to Intensive Care Unit in stable condition. After 23 h of mechanical ventilation, trachea was extubated. Hoarseness was noticed with low pitch voice following tracheal extubation. Patient’s respiration was comfortable and her pulse oximetry saturation on room air was 97%. Patient was started with routine steam inhalation and inhaled budesonide nebulisation. Patient’s weak voice persisted on the 2nd postoperative day also. Videolaryngoscopic examination revealed decreased movement of the left vocal cord suggestive of left vocal cord palsy. Patient’s nebulisation was continued. On postoperative day 10, patient’s voice became better with no hoarseness.