1229 Dual Neurostimulator Therapy for CSA and OSA in an Elderly Gentleman with Native Pacemaker

Abstract Introduction We describe a case of severe central sleep apnea with concomitant obstructive apnea treated with a stepwise approach with Transvenous phrenic nerve stimulation and Hypoglossal nerve stimulator. Report of case(s) 70 yo male with medical history of diabetes, chronic kidney disease stage 3, coronary artery disease with coronary artery bypass in 1997, aflutter with failed ablation (2015, persistent atrial fibrillation, bradycardia with pacemaker implantation (2016), lymphocytic leukemia, treated with methotrexate, underwent a home sleep study in 2018 which showed severe sleep apnea (AHI 55% and O2 nadir 72%). This was followed by a titration study which showed predominant CSA not amenable to CPAP, BPAP or BPAP ST. Echo was performed which showed LVEF 40%. Baseline in lab PSG was performed which showed AHI of 89.5/hour (225 central,36 mixed and 15 obstructive events). REM AHI: 65, REM RDI 65, Supine AHI 90/hour and supine RDI 90.1. Cheyne stokes breathing was observed throughout the study along with significant sleep hypoxia. Medical management failed and patient was not a candidate for ASV given low EF. Remede device was implanted in 2018 for management of CSA. For obstructive apnea, APAP was prescribed however patient tolerance remained poor with suboptimal control of OSA. Repeat PSG showed resolution of CSA and CCB with persistent severe obstructive events AHI 72. With control of CSA, patient underwent DISE which showed Anteroposterior collapse of the vellum qualifying the patient for Inspire. Conclusion Traditional treatment for CSA involves optimization of any underlying medical conditions and positive-pressure ventilation with certain limitations. In a subset of patients, CSA remains refractory to medical management and failure rates of PAP therapy remain high. Transvenous PNS significantly improves CSA severity, sleep quality, ventricular function, and QOL regardless of HF status and should be considered in patients with high CSA burden. Once CSA management is optimized, patients with high OSA burden and PAP intolerance can then be considered for HNS. Most of these patients with underlying heart failure may have native ICD or pacemaker, requiring careful assessment of device-device interaction. Support (if any)