Phrenic-Nerve Stimulation Implant

“Importantly, these patients slept better,” said Dr William T Abraham (Ohio State University, Columbus, OH) when presenting the study here at the Heart Failure Society of America 2013 Scientific Meeting. “Their sleep efficiency was significantly improved, and their time spent in that all-important [rapid-eye-movement] REM sleep was also significantly improved.” Those benefits were accompanied by “significant and clinically meaningful improvements” in oxygen desaturation, sleep arousals, and quality of life.

CSA afflicts about 37% of patients with heart failure and is associated with increased mortality and risk of other poor outcomes, Abraham observed. The remedē System (Respicardia), which consists of a pacemakerlike pulse generator with transvenous leads to one of the phrenic nerves, plus an exterior controller box, “delivers therapy in a way that regularizes the breathing pattern so as to avoid the apneas, rather than waiting until the apnea occurs and trying to stimulate the diaphragm to move again,” he said. “Just as we use cardiac pacemakers for cardiac rhythm management, this device is designed to deliver respiratory rhythm management.”

As discussant following Abraham’s presentation of the remedē System Pilot Study, Dr Christopher M O’Connor(Duke University, Durham, NC) said the results were promising but tentative pending larger randomized trials. He said the technique “has been used in the past to support respiratory paralysis, and this new transvenous approach is much less invasive than previous strategies.”

Conducted at 11 centers in different countries, the study enrolled patients with CSA by polysomnography conducted within the previous 60 days, with an apnea-hypopnea index (AHI) of at least 20 episodes per hour, only 20% of which could be attributed to obstructive sleep apneas (OSA). The one-fifth of patients with heart failure had to have been stable on standard meds for at least the prior month.

Of the 57 patients slated for implantation of the device, 49 were successfully implanted; the remainder failed due to problems placing the leads. Of those, 47 were available for evaluation of the primary end point, change in AHI at three months. Their apnea was fairly severe; the mean baseline AHI was 49.5.

Sleep Apnea Indexes (Episodes per Hour of Sleep) and REM Sleep Prevalence in Patients Using the remedē System

At three months, patients showed a 56% reduction in AHI, driven primarily by an 82% decline in the CSA index (p<0.0001 for both changes). Blood pressures were unaffected. The benefits persisted, to the same degree of significance, in the 44 patients who were available for evaluation at six months. Abraham said his group is still following the cohort, and there’s been no significant letup in the improvements.

“It might not be surprising that these patients also felt better,” Abraham said; 76% of patients reported feeling “markedly or moderate” improvement at global self-assessment.

Gerry Gajadharsingh writes:

 Any Osteopath will know that C3/4/5 keeps the diaphragm alive, this is a Mnemonic we learn as students to memorise the innervation of the phrenic nerve. So instead of going to the trouble of an invasive procedure, such as described above, what about ensuring that the function of the neck is as good as it can be, the patient’s diaphragm is working properly and most importantly teaching good breathing behavior. About 70% of the patients I see have sub-optimal breathing behaviour. Capnotraining is my preferred method for breathing re-education along side Osteopathic Manual Intervention.