When the Wires Cross Twice: A Case Report of the Perioperative Management of a Pediatric Patient With Both Abdominal Cardiac and Diaphragm Pacemakers

Down syndrome is associated with multisystem comorbidities complicating perioperative care, including cervical spine instability, airway abnormalities, and cardiac conduction defects. We report the case of a child with Down syndrome, high cervical myelopathy, progressing quadriplegia, and an abdominal cardiac pacemaker undergoing laparoscopic diaphragm pacer implantation. Management required advanced airway planning and coordinated pacemaker reprogramming to prevent device interference and arrhythmia. Continuous electrophysiologic monitoring was maintained throughout the procedure. The patient tolerated implantation without complication and achieved improved respiratory function with decreased ventilatory dependence. This case emphasizes the importance of multidisciplinary collaboration when multiple pacing systems coexist.