Clinical Trial Details
— Status: Completed
Administrative data
NCT number |
NCT04716504 |
Other study ID # |
APHP201072 |
Secondary ID |
|
Status |
Completed |
Phase |
|
First received |
|
Last updated |
|
Start date |
January 23, 2021 |
Est. completion date |
April 30, 2021 |
Study information
Verified date |
October 2021 |
Source |
Assistance Publique - Hôpitaux de Paris |
Contact |
n/a |
Is FDA regulated |
No |
Health authority |
|
Study type |
Observational
|
Clinical Trial Summary
Prolonged mechanical ventilation has been shown to induce diaphragm dysfunction. Temporary
diaphragm pacing is an interesting lead to halt or slow diaphragm dysfunction. A detailed
description of the distal portion of the phrenic nerve would be the start for developing a
new surgical approach for diaphragm pacing. Its in that perspective that we are launching a
clinical observational study of the distal portion of the phrenic nerve in patients who
undergo minimally invasive thoracic surgey. We hypothetize that the density of the fatty
tissue surrounding the distal portion of the phrenic nerve might influence efficiency of the
electrode during diaphragm pacing. The objective of this study is to find a correlation
between the amount of fatty tissue around the nerve and the body mass index of individuals.
Description:
Implanted phrenic nerve stimulation is a validated technique to produce lung ventilation when
the neural drive to breathe is abolished (e.g. congenital central alveolar ventilation during
sleep, or during wakefulness in severe forms of the disease) or defective (e.g. periodic
breathing due to chronic heart failure), or when it cannot reach the phrenic spinal
motoneurons (e.g. high cervical spinal cord lesions). Several implantation techniques have
been described. They include the surgical implantation of contact electrodes in intimate
exposure with the trunk of the nerve, the laparoscopic implantation of hook electrodes within
the diaphragm in the vicinity of the phrenic nerve endings (ref), and transvenous approaches
that can be permanent (pacemaker like device) or temporary (central venous catheter-borne
electrodes). The surgical implantation of electrodes in contact with the phrenic nerve
("periphrenic electrodes") is the better established of these techniques, having been
described in the 1970s and continuously used since. Periphrenic electrodes have been
implanted at the bottom of the cervical path of the nerve. This cervical approach is quick
and easy to implement, but the results can be compromised by system damages resulting from
neck movements and by the fact that the phrenic nerve is often anatomically incomplete at
this level (namely above the junction with the accessory phrenic nerve). For these reasons,
periphrenic electrodes are typically implanted within the thorax, at the level of the vena
cava on the right and of the pulmonary hilum on the left. These locations are readily
accessible by use of video-assisted thoracoscopic surgery or thoracotomy. Careful dissection
of the phrenic nerve is necessary to separate it from the underlying anatomical plane and
create the necessary access to position the electrodes. The possibility to position
periphrenic electrodes over a segment of the phrenic nerve where it would be fully
constituted and to do so without the need for nerve dissection would render intrathoracic
phrenic nerve stimulation easier and safer to implement. It would also open the possibility
of temporary implantation. From the anatomical description of the terminal branching of the
phrenic nerve toward different portions of the diaphragm , we hypothesized that such "free"
segment would exist between the point where the phrenic nerve pathway leaves the
anterolateral angle of the pericardial base in direction of the diaphragm and the point where
the phrenic nerve branches before entering the diaphragm muscle mass. This study was
therefore designed to determine whether or not a free phrenic segment exists between the
cardiophrenic angle and the diaphragm, to describe the anatomical characteristics of this
segment, and to compare the nature, number and size of its constituting fibers with the
corresponding characteristics as identified at the usual site of implantation of
intrathoracic periphrenic electrodes. To this aim, we first performed a human cadaver study.
This study allowed us to describe a fatty tissue surrounding the phrenic nerve which density
vary from one patient to another, and from one side to the other. During routine surgical
interventions by minimally invasive approach, we want to complete our observation by
searching for a correlation between patients body mass index (BMI) and the density of fatty
tissue surrounding the phrenic nerve.
The patients, depending on their BMI will be divided in three categories: - Category 1: 18,5
kg/m2 < BMI < 24,9 kg/m2 / - Category 2: 25 kg/m2 < BMI < 29,9 kg/m2 / - Category 3: 30,0
kg/m2 < BMI < 34,9 kg/m2 Fifteen patients will be included in each category. A fifteen
seconds recording of each phrenic nerve during minimally invasive surgery will be reviewed by
2 independent observers in order to classify the phrenic nerve in three categories: - type 1:
pericadiophrenic bundle is free of any relevant surrounding fatty tissue / - Type 2:
pericardiophre-nic bundle is surrounded by one fringe of fatty tissue / - Type 3:
pericardiophrenic bundle is surrounded by multiple fringes of fatty tissue