Perioperative use of temporary diaphragm pacing in surgical patients with unilateral diaphragm dysfunction to decrease mechanical ventilation.

Abstract

Background: Unilateral diaphragmatic dysfunction, most commonly from phrenic nerve injury, is associated with difficult ventilator weaning and increased postoperative pulmonary complications. Diaphragm pacing prevents ventilator-induced diaphragm dysfunction and supports ventilation during periods of perioperative vulnerability. We report perioperative utilization of temporary diaphragm pacing in patients with pre-existing or anticipated postoperative unilateral diaphragmatic dysfunction.

Methods: This cohort analysis was derived from a prospective, institutional review board-approved database at a single institution. Eligible patients demonstrated unilateral diaphragmatic elevation on preoperative imaging or sustained intraoperative phrenic nerve injury or sacrifice. Subjects received a Food and Drug Administration-authorized temporary diaphragm pacing system with intramuscular electrodes placed in each hemidiaphragm and tunneled percutaneously. Diaphragm electromyography confirmed dysfunction and guided therapy. A disposable multichannel stimulator delivered postoperative stimulation. Primary outcomes included mechanical ventilation duration and postoperative respiratory complications.

Results: Between January 2020 and December 2025, 544 patients underwent diaphragm pacing implantation for all indications. Subgroup analysis identified 21 high-risk surgical patients with unilateral dysfunction (17 preoperative; 4 intraoperative phrenic injury). Procedures included cardiac (n = 16), thymectomy (n = 3), vascular (n = 1), and liver transplantation (n = 1). Mean age was 62 years. Diaphragm electromyography confirmed unilateral phrenic dysfunction in 20 of 21 patients. Diaphragm pacing was initiated immediately postoperatively with a mean duration of 14.4 days. Excluding 1 patient, mean mechanical ventilation duration was 12 hours. No pneumonias, device-related complications, or 30-day mortalities occurred.

Conclusion: Unilateral diaphragmatic dysfunction is an overlooked contributor to perioperative respiratory morbidity. In this high-risk surgical cohort, temporary diaphragm pacing was safe and associated with short mechanical ventilation durations and low postoperative pulmonary complication rates, supporting further prospective evaluation.