SCI
Katelyn Langford, DO
Resident Doctor
University of Pennsylvania
Orefield, Pennsylvania, United States
Anthony Ascoli, MD
Resident Physician
University of Pennsylvania
Philadelphia, Pennsylvania, United States
Abigail J. Kohler, BA, BSN
Medical Student
Perelman School of Medicine
PHILADELPHIA, Pennsylvania, United States
Benjamin Abramoff, MD, MS
Associate Professor; SCI director
University of Pennsylvania
Philadelphia, Pennsylvania, United States
Katelyn Langford, DO
University of Pennsylvania
Orefield, Pennsylvania, United States
Recurrent ventricular arrhythmias associated with diaphragmatic pacing in a patient with high cervical spinal cord injury.
Case Description:
A 36-year-old male with C2 ASIA A spinal cord injury and diaphragmatic pacing system (DPS) implantation 14 years prior presented with recurrent episodes of unresponsiveness. Initial evaluations and admissions to the hospital suggested seizure, autonomic dysreflexia, or psychogenic nonepileptic events. On subsequent admission, telemetry revealed ventricular tachyarrhythmias and periods of asystole linked to DPS activation. Continuous monitoring demonstrated premature ventricular contractions (PVCs) consistently time-locked to pacing.
Deactivation of the DPS immediately resolved arrhythmias but required temporary mechanical ventilation. Upon reactivation and voltage reduction in the left lead, diaphragmatic capture was maintained without arrhythmias. The patient was successfully weaned from mechanical ventilation, discharged home, and remained stable on the adjusted DPS settings at follow-up.
Discussions:
This case highlights a rare but potentially life-threatening complication of DPS. The likely mechanism involves ectopic ventricular depolarization from diaphragmatic stimulation, functioning similarly to premature ventricular beats. Patients with high cervical SCI may be particularly vulnerable due to baseline autonomic dysfunction. Recognition of DPS-related arrhythmias requires a high index of suspicion, particularly when unexplained cardiovascular or neurologic events occur as they may not be readily apparent on EKG. For physiatrists, this underscores the importance of vigilance in long-term device oversight, interdisciplinary coordination, and advocacy for early involvement of electrophysiology and device specialists when complications arise.
Conclusions:
While DPS provides substantial benefits for ventilator-dependent SCI patients by improving independence and reducing complications of prolonged mechanical ventilation, it may also precipitate cardiac arrhythmias. Physiatrists should be aware of this rare risk, maintain close monitoring of unexplained cardiovascular events, and collaborate with interdisciplinary teams to optimize device safety and maximize functional outcomes.
