Phrenic Nerve Pacing Using a Subxiphoid Robotic Approach Without Lung Isolation

This video demonstrates the implantation of bilateral phrenic nerve pacing leads using a robotic subxiphoid approach without lung isolation.

This approach was utilized because the patient presented with central hypoventilation and chronic high CO2 levels; and lung collapse was avoided to prevent postoperative atelectasis. This method also reduced operative time by allowing the procedure bilaterally without the need to undock and reposition the robotic system.

The bilateral phrenic nerve pacing system is suited to patients who are chronically dependent on mechanical ventilation because of upper motor neuron respiratory muscle paralysis or central alveolar hypoventilation—most commonly high cervical spinal cord injury, congenital or acquired central hypoventilation syndrome, or brainstem stroke—provided that the remaining phrenic nerve, lung, and diaphragm function are sufficient to accommodate electrical stimulation.

The critical selection criterion is an intact or surgically repairable phrenic nerve with a viable, nonatrophied diaphragm and reasonably preserved lung parenchyma. Patients in whom the phrenic nerves have completely degenerated, such as in advanced ALS, or whose diaphragm muscle has irreversibly atrophied, as in muscular dystrophy, are not suitable candidates.

The device is licensed across both adult and pediatric populations, making it currently the only device in the US approved for both adults and children. While some adult patients can be managed with unilateral or alternating stimulation, pediatric patients almost universally require bilateral pacing. In practice, this makes the device most applicable to tetraplegic patients seeking ventilator independence, children and adults with central hypoventilation syndrome, and those with bilateral diaphragm paralysis of central neurological origin—always with a clear exclusion of primary muscle or lower motor neuron disease and severe intrinsic lung disease.

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