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European Journal of Cardiovascular... Jul 2023Sleep disorder breathing is an important non-cardiovascular comorbidity in patients with heart failure (HF). However, central sleep apnoea (CSA) remains poorly diagnosed...
AIMS
Sleep disorder breathing is an important non-cardiovascular comorbidity in patients with heart failure (HF). However, central sleep apnoea (CSA) remains poorly diagnosed and treated. This post hoc analysis examined symptoms and quality of life in patients with CSA and HF following 12 months of transvenous phrenic nerve stimulation (TPNS) therapy.
METHODS AND RESULTS
Patients enrolled in the remedē System Pivotal trial were invited to complete self-reported questionnaires. Symptoms and responses to three validated questionnaires were examined. Percentage of patients noting an impairment was calculated at baseline. At 12 months, % of patients experiencing improvement, no change, or worsening was calculated. Shifts from symptom presence at baseline to absence at 12 months were assessed for those symptoms experienced by ≥50% of patients at baseline. Seventy-five patients were included. Most frequently reported symptoms were fatigue and daytime sleepiness. Following 12 months of TPNS, a variety of subjective improvements were observed; 45% of patients indicating cessation of daytime sleepiness, 44% cessation of fatigue/weakness, and 52% no longer having difficulty falling/staying asleep. Specific questions related to tiredness/fatigue, motivation, and chance of dozing provided an insight into potential areas of improvement. Furthermore, at least 60% of patients reported resolution of insomnia/fragmented sleep and snoring on therapy.
CONCLUSION
Adult patients with CSA and HF experience distressing symptoms and limitations. Transvenous phrenic nerve stimulation was found to improve many of these. Awareness of key symptoms or limitations patients experience can be used to inform the development of a CSA-specific patient questionnaire to identify CSA sooner and aid treatment decisions.
Topics: Adult; Humans; Treatment Outcome; Sleep Apnea, Central; Phrenic Nerve; Quality of Life; Sleep; Disorders of Excessive Somnolence; Heart Failure; Sleep Initiation and Maintenance Disorders; Fatigue
PubMed: 36125322
DOI: 10.1093/eurjcn/zvac086 -
Journal of Neurophysiology Sep 2021Plasticity is a hallmark of the respiratory neural control system. Phrenic long-term facilitation (pLTF) is one form of respiratory plasticity characterized by...
Plasticity is a hallmark of the respiratory neural control system. Phrenic long-term facilitation (pLTF) is one form of respiratory plasticity characterized by persistent increases in phrenic nerve activity following acute intermittent hypoxia (AIH). Although there is evidence that key steps in the cellular pathway giving rise to pLTF are localized within phrenic motor neurons (PMNs), the impact of AIH on the strength of breathing-related synaptic inputs to PMNs remains unclear. Furthermore, the functional impact of AIH is enhanced by repeated/daily exposure to AIH (dAIH). Here, we explored the effects of AIH versus 2 wk of dAIH preconditioning on spontaneous and evoked phrenic responses in anesthetized, paralyzed, and mechanically ventilated rats. Evoked phrenic potentials were elicited by respiratory cycle-triggered lateral funiculus stimulation at the C2 spinal level delivered before and 60 min post-AIH (or the equivalent in time controls). Charge-balanced biphasic pulses (100 μs/phase) of progressively increasing intensity (100-700 μA) were delivered during the inspiratory and expiratory phases of the respiratory cycle. Although robust pLTF (∼60% from baseline) was observed after a single exposure to moderate AIH (3 × 5 min; 5-min intervals), there was no effect on evoked phrenic responses, contrary to our initial hypothesis. However, in rats preconditioned with dAIH, baseline phrenic nerve activity and evoked responses were increased, suggesting that repeated exposure to AIH enhances functional synaptic strength when assessed using this technique. The impact of daily AIH preconditioning on synaptic inputs to PMNs raises interesting questions that require further exploration. Two weeks of daily acute intermittent hypoxia (dAIH) preconditioning enhanced stimulus-evoked phrenic responses to lateral funiculus stimulation (targeting respiratory bulbospinal projection to phrenic motor neurons). Furthermore, dAIH preconditioning enhanced baseline phrenic motor output responses to maximal chemoreflex activation in intact rats.
Topics: Animals; Evoked Potentials; Hypoxia; Male; Motor Neurons; Neuronal Plasticity; Phrenic Nerve; Rats; Rats, Sprague-Dawley
PubMed: 34260289
DOI: 10.1152/jn.00112.2021 -
Annals of Biomedical Engineering Apr 2016The primary goal of this computational modeling study was to better quantify the relative distance of the phrenic nerves to areas where cryoballoon ablations may be...
The primary goal of this computational modeling study was to better quantify the relative distance of the phrenic nerves to areas where cryoballoon ablations may be applied within the left atria. Phrenic nerve injury can be a significant complication of applied ablative therapies for treatment of drug refractory atrial fibrillation. To date, published reports suggest that such injuries may occur more frequently in cryoballoon ablations than in radiofrequency therapies. Ten human heart-lung blocs were prepared in an end-diastolic state, scanned with MRI, and analyzed using Mimics software as a means to make anatomical measurements. Next, generated computer models of ArticFront cryoballoons (23, 28 mm) were mated with reconstructed pulmonary vein ostias to determine relative distances between the phrenic nerves and projected balloon placements, simulating pulmonary vein isolation. The effects of deep seating balloons were also investigated. Interestingly, the relative anatomical differences in placement of 23 and 28 mm cryoballoons were quite small, e.g., the determined difference between mid spline distance to the phrenic nerves between the two cryoballoon sizes was only 1.7 ± 1.2 mm. Furthermore, the right phrenic nerves were commonly closer to the pulmonary veins than the left, and surprisingly tips of balloons were further from the nerves, yet balloon size choice did not significantly alter calculated distance to the nerves. Such computational modeling is considered as a useful tool for both clinicians and device designers to better understand these associated anatomies that, in turn, may lead to optimization of therapeutic treatments.
Topics: Cryosurgery; Heart Atria; Humans; Magnetic Resonance Imaging; Models, Biological; Phrenic Nerve; Pulmonary Veins
PubMed: 26168718
DOI: 10.1007/s10439-015-1379-3 -
Acta Neurochirurgica Mar 2021Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from...
BACKGROUND
Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from injury. The most common nerves available for grafting include C5 and C6. During the surgical exposure of C5 and C6, the phrenic nerve is anatomically anterior to the cervical spinal nerves, making it vulnerable to injury while performing the dissection and nerve stump to graft coaptation. We describe a novel technique that protects the phrenic nerve from injury during supraclavicular brachial plexus exposure and grafting of C5 or upper trunk ruptures or neuromas in-continuity.
METHODS
A 4-step technique is illustrated: (1) The normal anatomic relationships of the phrenic nerve anterior to C5 is displayed in the face of the traumatic scarring. (2) The C5 spinal nerve stump is then transposed from its anatomic position posterior to the phrenic nerve to an anterior position. (3) The C5 stump is then moved medially for retrograde neurolysis of C5 from its phrenic nerve contribution. The graft coaptation to C5 is performed in this medial position, which minimizes retraction of the phrenic nerve. (4) The normal anatomic relationship of the phrenic nerve and the C5 nerve graft is restored.
RESULTS
We have been routinely relocating the C5 spinal nerve stump around the phrenic nerve for the past 10 years. We have experienced no adverse respiratory events.
CONCLUSION
This technique facilitates surgical exposure and prevents iatrogenic injury on the phrenic nerve during nerve reconstruction.
Topics: Brachial Plexus; Brachial Plexus Neuropathies; Humans; Iatrogenic Disease; Nerve Transfer; Neurosurgical Procedures; Peripheral Nerve Injuries; Phrenic Nerve; Plastic Surgery Procedures
PubMed: 33507373
DOI: 10.1007/s00701-021-04713-6 -
Journal of Cancer Research and... Dec 2022This study aimed to analyze the cases of phrenic nerve injury caused by the percutaneous microwave ablation of lung tumors conducted at our center and to explore the...
OBJECTIVE
This study aimed to analyze the cases of phrenic nerve injury caused by the percutaneous microwave ablation of lung tumors conducted at our center and to explore the risk factors.
MATERIALS AND METHODS
The data of 455 patients who underwent the percutaneous microwave ablation of lung tumors at the Department of Interventional Radiology, First Affiliated Hospital of Fujian Medical University from July 2017 to October 2021, were retrospectively analyzed. The cases of phrenic nerve injury after the percutaneous ablation were reported to analyze the risk factors involved, such as the shortest distance between tumor margin and phrenic nerve, tumor size, and ablation energy. The groups were divided based on the shortest distance between the tumor edge and the phrenic nerve into group 1, d ≤ l cm; group 2, 1 < d ≤2 cm; and group 3, d >2 cm. Lesions with a distance ≤2 cm were compared in terms of tumor size and ablation energy.
RESULTS
Among the 455 patients included in this study, 348 had primary lung cancer, and 107 had oligometastatic cancer. A total of 579 lesions were detected, with maximum diameter of 1.27 ± 0.55 cm, and the ablation energy was 9,000 (4,800-72,000) J. Six patients developed phrenic nerve injury, with an incidence of 1.32%. For these six patients, the shortest distance from the lesion edge to the phrenic nerve was 0.75 ± 0.48 cm, and the ablation energy was 10,500 (8,400-34,650) J. There were statistically significant differences in phrenic nerve injury among groups 1, 2, and 3 (P < 0.05). In patients with a distance (d) ≤ 2 cm, there were no significant differences in tumor diameter and energy between the phrenic nerve injury group and the non-injury group (P = 0.80; P = 0.41). In five out of six patients, the diaphragm level completely recovered to the pre-procedure state, and the recovery time of the phrenic nerve was 9.60 ± 5.60 months. Another one was re-examined 11 months after the procedure, and the level of the diaphragm on the affected side had partially recovered.
CONCLUSIONS
Phrenic nerve injury is a rare but not negligible complication of thermal ablation and is more likely to occur in lesions with a distance ≤2 cm from the phrenic nerve.
Topics: Humans; Catheter Ablation; Phrenic Nerve; Retrospective Studies; Microwaves; Lung Neoplasms; Treatment Outcome
PubMed: 36647962
DOI: 10.4103/jcrt.jcrt_1254_22 -
Journal of Neurophysiology Jul 2019In aging Fischer 344 rats, phrenic motor neuron loss, neuromuscular junction abnormalities, and diaphragm muscle (DIAm) sarcopenia are present by 24 mo of age, with...
In aging Fischer 344 rats, phrenic motor neuron loss, neuromuscular junction abnormalities, and diaphragm muscle (DIAm) sarcopenia are present by 24 mo of age, with larger fast-twitch fatigue-intermediate (type FInt) and fast-twitch fatigable (type FF) motor units particularly vulnerable. We hypothesize that in old rats, DIAm neuromuscular transmission deficits are specific to type FInt and/or FF units. In phrenic nerve/DIAm preparations from rats at 6 and 24 mo of age, the phrenic nerve was supramaximally stimulated at 10, 40, or 75 Hz. Every 15 s, the DIAm was directly stimulated, and the difference in forces evoked by nerve and muscle stimulation was used to estimate neuromuscular transmission failure. Neuromuscular transmission failure in the DIAm was observed at each stimulation frequency. In the initial stimulus trains, the forces evoked by phrenic nerve stimulation at 40 and 75 Hz were significantly less than those evoked by direct muscle stimulation, and this difference was markedly greater in 24-mo-old rats. During repetitive nerve stimulation, neuromuscular transmission failure at 40 and 75 Hz worsened to a greater extent in 24-mo-old rats compared with younger animals. Because type IIx and/or IIb DIAm fibers (type FInt and/or FF motor units) display greater susceptibility to neuromuscular transmission failure at higher frequencies of stimulation, these data suggest that the age-related loss of larger phrenic motor neurons impacts nerve conduction to muscle at higher frequencies and may contribute to DIAm sarcopenia in old rats. Diaphragm muscle (DIAm) sarcopenia, phrenic motor neuron loss, and perturbations of neuromuscular junctions (NMJs) are well described in aged rodents and selectively affect FInt and FF motor units. Less attention has been paid to the motor unit-specific aspects of nerve-muscle conduction. In old rats, increased neuromuscular transmission failure occurred at stimulation frequencies where FInt and FF motor units exhibit conduction failures, along with decreased apposition of pre- and postsynaptic domains of DIAm NMJs of these units.
Topics: Aging; Animals; Diaphragm; Female; Male; Motor Neurons; Muscle Fatigue; Muscle Fibers, Fast-Twitch; Neuromuscular Junction; Phrenic Nerve; Rats; Rats, Inbred F344; Synaptic Potentials
PubMed: 31042426
DOI: 10.1152/jn.00061.2019 -
The Journal of Hand Surgery Oct 2023In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle...
PURPOSE
In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios.
METHODS
A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis).
RESULTS
Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4.
CONCLUSIONS
A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves.
TYPE OF STUDY/LEVEL OF EVIDENCE
Therapeutic V.
Topics: Adult; Humans; Gracilis Muscle; Phrenic Nerve; Brachial Plexus Neuropathies; Nerve Expansion; Nerve Transfer; Brachial Plexus; Elbow Joint; Retrospective Studies; Free Tissue Flaps; Birth Injuries; Range of Motion, Articular; Treatment Outcome; Recovery of Function
PubMed: 35534324
DOI: 10.1016/j.jhsa.2022.03.006 -
Neuroscience Research Jan 2022Abdominal muscles are involved in respiration and locomotion. In the isolated pons-spinal cord-rib attached preparation from neonatal rat, the phrenic nerve and...
Abdominal muscles are involved in respiration and locomotion. In the isolated pons-spinal cord-rib attached preparation from neonatal rat, the phrenic nerve and abdominal muscles show inspiratory and expiratory activity, respectively. Using this preparation, we investigated whether the bath application of NMDA and 5-HT could evoke locomotor activities in the fourth cervical ventral root (C4VR), phrenic nerve, and abdominal muscle nerve (ilioinguinal nerve, IIG-n). We also observed rib and abdominal muscle movements visually. The phrenic nerve and C4VR showed inspiratory activity consistently under the control conditions, whereas IIG-n showed expiratory activity only at the beginning of the experiment. During the chemically-induced locomotion, both C4VR and IIG-n showed locomotor activity, and IIG-n in particular showed flexor activity. During the flexor activity, lateral bending of the rib cage to the recording site was observed. The phrenic nerve showed weak or no apparent locomotor activity. We concluded that the central pattern generator (CPG) for locomotion provides stronger excitatory synaptic inputs to C4 motoneurons innervating neck and shoulder muscles than the inputs to the phrenic motoneurons. Thus, the locomotor CPG provides a suitable amount of inputs to the functionally proper motoneurons. This preparation will be useful to explore how the respiratory and locomotor CPGs select proper motoneurons to give synaptic inputs and are coordinated with each other.
Topics: Abdominal Muscles; Animals; Animals, Newborn; Locomotion; N-Methylaspartate; Phrenic Nerve; Rats; Serotonin; Spinal Cord
PubMed: 34324893
DOI: 10.1016/j.neures.2021.07.004 -
Annals of Plastic Surgery Feb 2021In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but...
INTRODUCTION
In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years.
PATIENTS AND METHODS
Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years.
RESULTS
Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms.
CONCLUSIONS
The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.
Topics: Accessory Nerve; Brachial Plexus; Brachial Plexus Neuropathies; Humans; Middle Aged; Nerve Transfer; Phrenic Nerve; Range of Motion, Articular; Recovery of Function; Treatment Outcome
PubMed: 33346562
DOI: 10.1097/SAP.0000000000002611 -
Annals of Vascular Surgery Jan 2020The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic... (Comparative Study)
Comparative Study
Anatomic Variation of the Phrenic Nerve and Brachial Plexus Encountered during 100 Supraclavicular Decompressions for Neurogenic Thoracic Outlet Syndrome with Associated Postoperative Neurologic Complications.
BACKGROUND
The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications.
METHODS
A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups.
RESULTS
In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function.
CONCLUSIONS
Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.
Topics: Adult; Brachial Plexus; Brachial Plexus Neuropathies; Decompression, Surgical; Female; Humans; Male; Maryland; Peripheral Nerve Injuries; Philadelphia; Phrenic Nerve; Retrospective Studies; Risk Assessment; Risk Factors; Thoracic Outlet Syndrome; Treatment Outcome
PubMed: 31207398
DOI: 10.1016/j.avsg.2019.04.010