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

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.