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Monitoring of the pleura and diaphragm in patients with CRT is not routine practice. Functional diaphragmatic monitoring is not performed prior to cardiac surgery, but diaphragmatic mobility is checked routinely during postoperative intensive care unit (ICU) stay. Postoperative phrenic nerve palsy caused by excessive traction from the chest tube was not associated with postoperative complications (21). Postoperative diaphragmatic palsy is usually a consequence of postoperative cough and straining on the chest tube. In contrast to the short-term respiratory effects of diaphragmatic palsy, long-term dysfunction is likely due to chronic injury of the diaphragmatic muscle because the normal postoperative recovery of the diaphragm is more marked than that of the phrenic nerve. Phrenic muscle atrophy can also predispose to diaphragmatic dysfunction later on (18). In most cases, permanent phrenic nerve injury is associated with a long-term life-threatening condition. The patients usually develop respiratory failure and require mechanical ventilation. An animal model showed that persistent diaphragmatic paralysis can be partially reversed by stimulating with single or multiple electrical pulses over a period of four weeks [ 72 ]. Compared with permanent pacing, electrical stimulation can maintain intrinsic ventricular activation even after diaphragmatic paralysis. This provides partial contractile function to the diaphragm, which can prevent respiratory failure. Experimental evidence shows that the recovery of diaphragmatic movement can be achieved up to an output of about 15 V. Stimulating phrenic nerve for more than two weeks may be needed to improve diaphragmatic function completely [ 72 ].

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