Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Bethanien Hospital, Solingen, Germany.
Curr Opin Pulm Med. 2019 Nov;25(6):561-569. doi: 10.1097/MCP.0000000000000606.
Central sleep apnoea (CSA) is highly prevalent in patients with heart failure and substantially impairs survival. If optimal cardiac treatment fails, alternative therapeutical options, including positive airway pressure (PAP) therapies, drugs or application of oxygen and carbon dioxide are considered to suppress CSA which interfere with the complex underlying pathophysiology. Most recently, unilateral phrenic nerve stimulation (PNS) has been studied in these patients. Therefore, there is an urgent need to critically evaluate efficacy, potential harm and positioning of PNS in current treatment algorithms.
Data from case series and limited randomized controlled trials demonstrate the feasibility of the invasive approach and acceptable peri-interventional adverse events. PNS reduces CSA by 50%, a figure comparable with continuous PAP or oxygen. However, PNS cannot improve any comorbid upper airways obstruction. A number of fatalities due to malignant cardiac arrhythmias or other cardiac events have been reported, although the association with the therapy is unclear.
PNS offers an additional option to the therapeutical portfolio. Intervention-related adverse events and noninvasive alternatives need clear discussion with the patient. The excess mortality in the SERVE-HF study has mainly been attributed to sudden cardiac death. Therefore, previous cardiac fatalities under PNS urge close observation in future studies as long-term data are missing.
心力衰竭患者中中枢性睡眠呼吸暂停（CSA）的患病率很高，并且极大地降低了生存率。如果最佳的心脏治疗失败，则可以考虑替代治疗方法，包括正压通气（PAP）治疗、药物或应用氧气和二氧化碳，以抑制干扰复杂潜在病理生理学的 CSA。最近，单侧膈神经刺激（PNS）已在这些患者中进行了研究。因此，迫切需要批判性地评估 PNS 在当前治疗算法中的疗效、潜在危害和定位。
来自病例系列和有限的随机对照试验的数据表明，该有创方法具有可行性，且围手术期不良事件可接受。PNS 可将 CSA 降低 50%，这一数字与持续 PAP 或氧气相当。但是，PNS 不能改善任何并存的上呼吸道阻塞。尽管与治疗的相关性尚不清楚，但已经有报道称由于恶性心律失常或其他心脏事件而导致的一些死亡。
PNS 为治疗方案提供了另一种选择。与干预相关的不良事件和无创替代方法需要与患者进行明确的讨论。SERVE-HF 研究中的超额死亡率主要归因于心脏性猝死。因此，在未来的研究中，由于缺乏长期数据，需要密切观察之前 PNS 治疗下的心脏性死亡。
