Dual Implementation of Phrenic and Hypoglossal Nerve Stimulators in a Patient With Obstructive and Central Sleep Apnea and Associated Cardiac Arrhythmias.

When patients with obstructive sleep apnea (OSA) and central sleep apnea (CSA) fail to benefit from first-line therapies, combinations of new treatment modalities may be beneficial. The hypoglossal nerve stimulator (HNS) and phrenic nerve stimulator (PNS) are two exciting options in the management of OSA and CSA, respectively. A 72-year-old man with concurrent CSA and OSA underwent sequential implantation of a PNS followed by a unilateral HNS, and his response to each device was monitored with polysomnography (PSG). This patient also had a significant history of atrial flutter and premature ventricular contractions refractory to ablation, which his cardiologist had attributed to his sleep apnea. Implantation of the PNS device diminished the features of CSA on follow-up PSG. While his Apnea-Hypopnea Index (AHI) improved from 66 events/h to 30 events/h, the obstructive component of his sleep apnea remained elevated. Continued obstructive events and daytime sleepiness prompted implantation of the HNS. A follow-up PSG revealed an AHI of 12 events/h and significant improvement in nighttime oxygenation. Thus, simultaneously reducing upper airway collapse and central ventilatory instability may confer greater improvement than either approach used alone. Utilizing hypoglossal and phrenic nerve stimulator devices in unison may be an efficacious approach in the management of complex cases of sleep apnea.