Skip to main content
SpringerLink
Log in

Phrenic nerve palsy during ablation of atrial fibrillation using a 28-mm cryoballoon catheter: predictors and prevention

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

The purposes of this study were to determine whether predictors of phrenic nerve palsy (PNP) exist and to test whether a standardized ablation protocol may prevent PNP during cryoballoon (CB) ablation using the 28 mm CB.

Methods

Three-dimensional (3D) geometry of the pulmonary veins (PV) and their relationship to the superior vena cava (SVC) was analyzed. Phrenic nerve (PN) stimulation was performed during ablation of the right-sided PVs with a 28-mm CB. The freezing cycle was immediately terminated in case of loss of PN capture.

Results

Sixty-five patients (age, 58 ± 11 years; ejection fraction, 0.59 ± 0.06; left atrial size, 40 ± 5 mm) with paroxysmal atrial fibrillation were included. No persistent PNP was observed. Transient PNP occurred in 4 of 65 patients (6 %). PN function normalized within 24 h in all four patients. A short distance between the right superior PV and the SVC was significantly associated with PNP, but left atrial and 3D PV anatomy were not. Low temperature early during the freezing cycle (<−41 °C at 30 s) predicted PNP with a sensitivity and a specificity of 100 and 98 %, respectively.

Conclusion

The anatomical relationship between the right superior PV and the SVC is a preprocedural predictor for the development of transient PNP, and low temperature early during ablation at the right superior PV is a sensitive warning sign of impending PNP. Despite the use of the 28 mm CB, transient PNP occurred in 6 % of patients undergoing CB ablation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Haissaguerre, M., Jais, P., Shah, D. C., Takahashi, A., Hocini, M., Quiniou, G., et al. (1998). Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. The New England Journal of Medicine, 339, 659–666.

    Article  PubMed  CAS  Google Scholar 

  2. Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2010). Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation: Arrhythmia and Electrophysiology, 3, 32–38.

    Article  Google Scholar 

  3. Calkins, H., Kuck, K. H., Cappato, R., Brugada, J., Camm, A. J., Chen, S. A., et al. (2012). 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm, 9, 632–696.

    Article  PubMed  Google Scholar 

  4. Van Belle, Y., Janse, P., Rivero-Ayerza, M. J., Thornton, A. S., Jessurun, E. R., Theuns, D., et al. (2007). Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome. European Heart Journal, 28, 2231–2237.

    Article  PubMed  Google Scholar 

  5. Neumann, T., Vogt, J., Schumacher, B., Dorszewski, A., Kuniss, M., Neuser, H., et al. (2008). Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. Journal of the American College of Cardiology, 52, 273–278.

    Article  PubMed  Google Scholar 

  6. Chun, K. R., Schmidt, B., Metzner, A., Tilz, R., Zerm, T., Koster, I., et al. (2009). The ‘single big cryoballoon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. European Heart Journal, 30, 699–709.

    Article  PubMed  Google Scholar 

  7. Kuhne, M., Suter, Y., Altmann, D., Ammann, P., Schaer, B., Osswald, S., et al. (2010). Cryoballoon versus radiofrequency catheter ablation of paroxysmal atrial fibrillation: biomarkers of myocardial injury, recurrence rates and pulmonary vein reconnection patterns. Heart Rhythm, 7, 1770–1776.

    Google Scholar 

  8. Packer, D., Irwin, J. M., Champagne, J., Guerra, P., Dubuc, M., Wheelan, K., et al. (2010). Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front STOP-AF pivotal trial. Journal of the American College of Cardiology, 55, E3015–E3016.

    Google Scholar 

  9. Andrade, J. G., Khairy, P., Guerra, P. G., Deyell, M. W., Rivard, L., Macle, L., et al. (2011). Efficacy and safety of cryoballoon ablation for atrial fibrillation: a systematic review of published studies. Heart Rhythm, 8, 1444–1451.

    Article  PubMed  Google Scholar 

  10. Sanchez-Quintana, D., Cabrera, J. A., Climent, V., Farre, J., Weiglein, A., & Ho, S. Y. (2005). How close are the phrenic nerves to cardiac structures? Implications for cardiac interventionalists. Journal of Cardiovascular Electrophysiology, 16, 309–313.

    Article  PubMed  Google Scholar 

  11. Van Belle, Y., Knops, P., Janse, P., Rivero-Ayerza, M., Jessurun, E., Szili-Torok, T., et al. (2009). Electro-anatomical mapping of the left atrium before and after cryothermal balloon isolation of the pulmonary veins. Journal of Interventional Cardiac Electrophysiology, 25, 59–65.

    Article  PubMed  Google Scholar 

  12. Andrade, J., Dubuc, M., Guerra, P.G., Macle, L., Mondésert, B., Rivard, L., et al. (2012). The biophysics and biomechanics of cryoballoon ablation. Pacing and Clinical Electrophysiology, 35, 1162–1168

    Google Scholar 

  13. Schmidt, B., Chun, K. R., Ouyang, F., Metzner, A., Antz, M., & Kuck, K. H. (2008). Three-dimensional reconstruction of the anatomic course of the right phrenic nerve in humans by pace mapping. Heart Rhythm, 5, 1120–1126.

    Article  PubMed  Google Scholar 

  14. Kojodjojo, P., O’Neill, M. D., Lim, P. B., Malcolm-Lawes, L., Whinnett, Z. I., Salukhe, T. V., et al. (2010). Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation. Heart, 96, 1379–1384.

    Article  PubMed  Google Scholar 

  15. Nieto-Tolosa, J., Rodriguez-Sanchez, D., Hurtado-Martinez, J.A., Pinar-Bermudez, E., Penafiel-Verdu, P., Sanchez-Munoz, J.J., et al. (2011). Phrenic nerve identification with cardiac multidetector computed tomography. Revista Española de Cardiología, 64, 942–944

    Google Scholar 

  16. Horton, R., Di Biase, L., Reddy, V., Neuzil, P., Mohanty, P., Sanchez, J., et al. (2010). Locating the right phrenic nerve by imaging the right pericardiophrenic artery with computerized tomographic angiography: implications for balloon-based procedures. Heart Rhythm, 7, 937–941.

    Article  PubMed  Google Scholar 

  17. Okumura, Y., Henz, B. D., Bunch, T. J., Dalegrave, C., Johnson, S. B., & Packer, D. L. (2009). Distortion of right superior pulmonary vein anatomy by balloon catheters as a contributor to phrenic nerve injury. Journal of Cardiovascular Electrophysiology, 20, 1151–1157.

    Article  PubMed  Google Scholar 

  18. Kim, D. H., Lu, N., Ghaffari, R., Kim, Y. S., Lee, S. P., Xu, L., et al. (2011). Materials for multifunctional balloon catheters with capabilities in cardiac electrophysiological mapping and ablation therapy. Nature Materials, 10, 316–323.

    Article  PubMed  CAS  Google Scholar 

  19. Franceschi, F., Dubuc, M., Guerra, P. G., & Khairy, P. (2011). Phrenic nerve monitoring with diaphragmatic electromyography during cryoballoon ablation for atrial fibrillation: the first human application. Heart Rhythm, 8, 1068–1071.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, University of Basel Hospital, Petersgraben 4, 4031, Basel, Switzerland

    Michael Kühne, Sven Knecht, David Altmann, Beat Schaer, Stefan Osswald & Christian Sticherling

  2. Department of Radiology, University of Basel Hospital, Basel, Switzerland

    Nadine Kawel

  3. Division of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland

    Peter Ammann

Authors
  1. Michael Kühne
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sven Knecht
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David Altmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nadine Kawel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Peter Ammann
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Beat Schaer
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Stefan Osswald
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Christian Sticherling
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Kühne.

Additional information

Editorial Commentary

Kuhne et al. evaluated whether a standardized protocol including phrenic nerve stimulation and the use of a large size (28 mm) balloon might prevent phrenic nerve palsy during Cryoballoon ablation of the right superior pulmonary vein. Although no case of persistent phrenic nerve palsy was reported, transient palsy occurred in 6% of patients. These findings support the notion that larger balloon sizes do not provide enough protection against the risk of phrenic nerve paralysis. Of note, the authors found that a short distance between the right superior pulmonary vein and the superior vena cava, and low temperature (< 41 degrees Celsius) during the first 30 seconds of the freezing cycle were predictors of phrenic nerve palsy with very high sensitivity (100%) and specificity (98%). Further studies are warranted to define whether a pre-operative assessment of the distance between the right superior pulmonary vein and the superior vena cava might be useful to select patients with the lower risk of phrenic nerve palsy during Cryoballoon ablation of the right superior pulmonary vein.

M. Kühne and S. Knecht contributed equally to this manuscript

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kühne, M., Knecht, S., Altmann, D. et al. Phrenic nerve palsy during ablation of atrial fibrillation using a 28-mm cryoballoon catheter: predictors and prevention. J Interv Card Electrophysiol 36, 47–54 (2013). https://doi.org/10.1007/s10840-012-9740-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-012-9740-z

Keywords

Search

Navigation