Diaphragmatic paralysis is a relatively rare complication of congenital cardiac surgery in children. Its occurrence is associated with increased morbidity and mortality. A high index of clinical suspicion, utilization of bedside diagnostic tools, and a policy of early plication for certain patients may lead to improved outcomes.

We are grateful to Talwar et al for their comments on our article, and we are also thankful to the World Journal for Pediatric and Congenital Heart Surgery for giving us the opportunity to reply. We are all aware of the importance of respiratory function in the outcome of Fontan operations. In general, we have managed patients according to their symptoms; the frequent presence of a mild to moderate degree of respiratory distress following extubation does not usually result in specific management unless it persists for a long time or is associated with desaturation from the start. Therefore, surgical intervention for diaphragmatic paralysis (DP) is usually reserved for more severe instances of respiratory distress following extubation. The mentioned patient who underwent a Fontan procedure tolerated his DP. He was extubated on postoperative day 1 and continued to have only mild to moderate respiratory distress without a significant effect on arterial oxygen saturation. We considered the potential need for diaphragmatic plication. But consistent with our policy, we observed the patient for several days during which time he was able to compensate without need for surgery. We believe that the patient's age (our patients undergoing Fontan procedures are usually operated beyond 6 years of age) contributed to his ability to tolerate DP, with only mild respiratory distress and without major effect on cardiovascular dynamics. The patient did receive inotropic support for several days. Younger patients are less likely to tolerate DP from a respiratory standpoint. After completing this retrospective study, our threshold for investigation and diaphragmatic plication for early clinical suspicion of postoperative DP has been lowered.We have compared the incidence of DP in relation to individual cardiac lesions and procedures in our series to those that have been previously reported by others. The incidence of DP following Glenn superior cavopulmonary anastomosis in our series was 8.6% (3 of 34). Other publications described the incidence ranging from 6.2% to 20%. The DP occurred in one of the three patients undergoing Fontan procedures in our series, while the incidence has been estimated to be 17.6% to 19% by others. 1-3 Despite the differences between our lesion-specific rates of the occurrence of DP and some that have been reported previously, our overall incidence of DP is near the lower overall rates in published reports.With respect to the second comment by Talwar and associates, we read with great interest your remarks concerning the transabdominal approach for plication of the diaphragm in cases of bilateral DP. In patients who had bilateral paralysis, such an approach does make it possible to plicate both sides in one surgical procedure. But we generally recommend performing two separate procedures with a time interval between procedures, as we have seen some patients with bilateral diaphragmatic dysfunction for whom extubation of the trachea was possible after plication of one side only, instead of opening the abdomi...