Intraoperative phrenic stimulation offsets diaphragm fiber weakness during cardiothoracic surgery

Abstract

RationaleMechanical ventilation rapidly induces slow and fast fiber contractile dysfunction in the human diaphragm, which could be attenuated by phrenic nerve stimulation. Here, we present data from a controlled trial of intraoperative phrenic stimulation to offset slow and fast fiber contractile dysfunction and myofilament protein derangements.ObjectivesIn this study, we tested the hypothesis that intraoperative hemidiaphragm stimulation would mitigate slow and fast fiber loss of contractile function in the human diaphragm.MethodsNineteen adults (9 females, age 59 ±12 years) consented to participate. Unilateral phrenic twitch stimulation was applied for one minute, every 30 minutes during cardiothoracic surgery. Thirty minutes following the last stimulation bout, biopsies were obtained from the hemidiaphragms for single fiber force mechanics and quantitation of thin filament protein abundance. Effects of stimulation and fiber type on force mechanics were evaluated with linear mixed models with the subject treated as a random intercept effect.Measurements and Main ResultsSubjects underwent 6 ±2 hemidiaphragm stimulations at 17 ±6 mA, during 278 ±68 minutes of mechanical ventilation. In slow-twitch fibers, cross-sectional area (p<0.0001) and specific force (p<0.0005) were significantly greater on the stimulated side. Longer-duration surgeries were associated with lower slow-twitch specific force (p<0.001). Stimulation did not alter contractile function of fast-twitch fibers or calcium-sensitivity in either fiber type. There were no differences in abundance or phosphorylation of myofilament proteins.ConclusionUnilateral phrenic stimulation during open chest surgery preserved contractile function of slow-twitch diaphragm fibers, but had no effect on relative abundance of sarcomeric proteins.

Intraoperative Hemi-Diaphragm Electrical Stimulation Demonstrates Attenuated Mitochondrial Function without Change in Oxidative Stress in Cardiothoracic Surgery Patients

“…The current findings contrast with our previous work, where hourly hemidiaphragm stimulation over the course of prolonged cardiovascular surgery significantly increased State 3 (PCI) and State 4 (leak) respiration [8]. In the same subjects presented here, this supramaximal phrenic stimulation regimen offset contractile dysfunction and atrophy of slow diaphragm fibers [19]. A precise intraoperative quantification of the stimulation intensity is not feasible, but supramaximal stimulation was targeted to preserve maximal force production.…”