Fluoroscopy of Spontaneous Breathing is More Sensitive Than Phrenic Nerve Stimulation for Detection of Right Phrenic Nerve Injury During Cryoballoon Ablation of Atrial Fibrillation

• Published in: Journal of cardiovascular electrophysiology Vol. 25; no. 8; pp. 859 - 865
• Main Authors: LINHART, MARKUS, NIELSON, ANNIKA, ANDRIÉ, RENÉ P., MITTMANN-BRAUN, ERICA L., STÖCKIGT, FLORIAN, KREUZ, JENS, NICKENIG, GEORG, SCHRICKEL, JAN W., LICKFETT, LARS M.
• Format: Journal Article
• Language: English
• Published: United States Blackwell Publishing Ltd 01.08.2014; Wiley Subscription Services, Inc
• Subjects: Adult; Aged; Anatomic Landmarks; atrial fibrillation; Atrial Fibrillation - diagnosis; Atrial Fibrillation - physiopathology; Atrial Fibrillation - surgery; catheter ablation; cryoballoon ablation; Cryosurgery - adverse effects; Diaphragm - innervation; Electric Stimulation; Female; Fluoroscopy; Humans; Length of Stay; Male; Middle Aged; Monitoring, Intraoperative - methods; Palpation; Paralysis - diagnosis; Paralysis - diagnostic imaging; Paralysis - etiology; Paralysis - physiopathology; Patient Discharge; Peripheral Nerve Injuries - diagnosis; Peripheral Nerve Injuries - diagnostic imaging; Peripheral Nerve Injuries - etiology; Peripheral Nerve Injuries - physiopathology; Phrenic Nerve - injuries; Phrenic Nerve - physiopathology; Phrenic Nerve - surgery; phrenic nerve injury; phrenic nerve stimulation; Predictive Value of Tests; Pulmonary Veins - diagnostic imaging; Pulmonary Veins - physiopathology; Pulmonary Veins - surgery; Recovery of Function; Respiration; Risk Factors; Time Factors; Treatment Outcome; atrial fibrillation; catheter ablation; cryoballoon ablation; phrenic nerve injury; phrenic nerve stimulation
• ISSN: 1045-3873; 1540-8167
• DOI: 10.1111/jce.12431

Monitoring of Phrenic Nerve During Cryoballoon Ablation Introduction Right phrenic nerve palsy (PNP) is a typical complication of cryoballoon ablation of the right‐sided pulmonary veins (PVs). Phrenic nerve function can be monitored by palpating the abdomen during phrenic nerve pacing from the superior vena cava (SVC pacing) or by fluoroscopy of spontaneous breathing. We sought to compare the sensitivity of these 2 techniques during cryoballoon ablation for detection of PNP. Methods and Results A total of 133 patients undergoing cryoballoon ablation were monitored with both SVC pacing and fluoroscopy of spontaneous breathing during ablation of the right superior PV. PNP occurred in 27/133 patients (20.0%). Most patients (89%) had spontaneous recovery of phrenic nerve function at the end of the procedure or on the following day. Three patients were discharged with persistent PNP. All PNP were detected first by fluoroscopic observation of diaphragm movement during spontaneous breathing, while diaphragm could still be stimulated by SVC pacing. In patients with no recovery until discharge, PNP occurred at a significantly earlier time (86 ± 34 seconds vs. 296 ± 159 seconds, P < 0.001). No recovery occurred in 2/4 patients who were ablated with a 23 mm cryoballoon as opposed to 1/23 patients with a 28 mm cryoballoon (P = 0.049). Conclusion Fluoroscopic assessment of diaphragm movement during spontaneous breathing is more sensitive for detection PNP as compared to SVC pacing. PNP as assessed by fluoroscopy is frequent (20.0%) and carries a high rate of recovery (89%) until discharge. Early onset of PNP and use of 23 mm cryoballoon are associated with PNP persisting beyond hospital discharge.