Archived case 223 · June 14-June 21, 2017
Case of the week
What medical problem does this patient have?
Images
Imaging findings
Additional radiographic findings: Normal heart size. Torturous descending thoracic aorta with atherosclerotic calcifications. Hyperlucent lungs and increased AP chest diameter. Bronchial wall thickening and bronchiectasis. Incidentally noted, there is a compression deformity of the T12 vertebral body. Answer Diagnosis: Respicardia device in a patient with a history of sleep apnea. The azygous and pericardiophrenic leads are in good position.
Answer
Diagnosis: Respicardia device in a patient with a history of sleep apnea. The azygous and pericardiophrenic leads are in good position.
DISCUSSION:
This elderly patient presented with central sleep apnea, chronic heart failure and atrial fibrillation. He received a Respicardia Remede implantable phrenic nerve stimulator with subjective improvement in his symptoms. One lead is typically positioned in a vein close to the phrenic nerve branches (in this case in the left pericardiophrenic vein). This delivers small electrical pulses to the phrenic nerve branch resulting in stimulation of the diaphragm to restore a normal breathing pattern. Improved breathing pattern is supposed to increase oxygenation, decrease activation of the sympathetic nervous system, and improve sleep quality, eventually resulting in better cardiovascular health. The system activates automatically during sleep. A portable tablet programmer allows for monitoring and changes in settings. The sensing lead in this case was positioned in a deep branch off low azygous vein.
Selected Readings:
1. Jagielski D, Ponikowski P, Augostini R, et al. Long-Term Safety and Efficacy of Transvenous Stimulation of the Phrenic Nerve for the Treatment of Central Sleep Apnea: Experience with the remede® System. Eur J Heart Fail 2016
2. Zhang XL, Ding N, Ni B, et al. Safety and feasibility of chronic transvenous phrenic nerve stimulation for treatment of central sleep apnea in heart failure patients. Clin Respir J 2015
3. Emani S and Abraham WT. Tranvenous phrenic nerve stimulation – a novel therapy for central sleep apnea in heart failure. European Cardiology 2012;8:44-50.
(Click for a larger image.)
The answer to this case was not published in the collection before it went offline; what survives is the history, the question and the images above.
Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.