Phrenic Nerve Injury and Diaphragmatic Paralysis Following Pacemaker Pulse Generator Replacement.

SESSION TYPE: Miscellaneous Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: We report, to our knowledge, the first case ever describing phrenic nerve injury and unilateral diaphragmatic paralysis following pacemaker pulse generator replacement.CASE PRESENTATION: A 75 year-old woman presented with syncope. She had a permanent pacemaker placed for sinus node dysfunction. Pacemaker interrogation revealed end-of-life battery status, and therefore generator exchange was scheduled. Under local anesthesia, an incision was made over the location of the existing generator and an electrocautery was used to free the generator that was explanted. The pacing threshold improvement was achieved with use of a silicone repair kit, and a new pulse generator was implanted. She developed an isolated hemoptysis but remained stable. A portable chest plain film showed a new left upper lobe opacity associated with elevation of the left diaphragm. Six weeks later, she continued to complaint of dyspnea with minimal exertion with no improvement. A repeat chest plain film showed persistent left diaphragmatic elevation. The patient's vital capacity was 1.62 liters (72 % of predicted) before the procedure and 1.22 liters (57% of predicted) after the left diaphragmatic paralysis. Subsequently, the patient underwent a successful diaphragmatic plication with significant postoperative clinical improvement and increased vital capacity.DISCUSSION: Phrenic nerve injury has been reported after penetrating or blunt traumatic neck injury and neck surgery1. It has been also described following internal jugular cannulation2,3 as well as subclavian vein cannulation, following cardiac radiofrequency ablation and after cardiac surgery. It was also reported after pacemaker placement, which was due to phrenic nerve compression by a pseudoaneurysm of the internal mammary artery. In our case, the pathophysiology of this injury can probably be explained by two possibilities. First, the use of electrocautery to dissect and remove the old pulse generator could lead to phrenic nerve damage by the generation of heat that was transmitted through the chest wall and damaging the nerve especially if that nerve was lying anterior to the subclavian vein. Second, the phrenic nerve might be damaged directed by the lidocaine injection, which in this case went through the chest wall and into the lung parenchyma leading to hemoptysis. We elected to perform diaphragmatic plication, as our patient was significantly symptomatic.CONCLUSIONS: Phrenic nerve injury with resulting diaphragmatic paralysis can occur after pacemaker battery change.1) McCaul JA, Hislop WS. Transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature. J R Coll Surg Edinb 2001; 46:186-1882) Rigg A, Hughes P, Lopez A, et al. Right phrenic nerve palsy as a complication of indwelling central venous catheters. Thorax 1997; 52:831-8333) Vest JV, Pereira MB, Senior RM. Phrenic nerve injury associated with venipuncture of the internal jugular vein. Chest 1980; 78:777-779DISCLOSURE: The following authors have nothing to disclose: Kassem Harris, Gregory Maniatis, Faraz Siddiqui, Theodore ManiatisNo Product/Research Disclosure InformationStaten Island University Hospital, Staten Island, NY.