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Optimal prevention method of phrenic nerve injury in superior vena cava isolation: efficacy of high-power, short-duration radiofrequency energy application on the risk points

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract 

Background or Purpose

Superior vena cava isolation (SVCI) is widely performed adjunctively to atrial fibrillation (AF) ablation. Right phrenic nerve injury (PNI) is a complication of this procedure. The purpose of the study is to determine the optimal PNI prevention method in SVCI.

Methods

A total of 1656 patients who underwent SVCI between 2009 and 2022 were retrospectively examined. PNI was diagnosed based on the diaphragm position and movement in the upright position on chest radiographs before and after SVCI.

Results

With the introduction of various PN monitoring systems over the years, the incidence of SVCI-associated PNI has decreased. However, complete PNI avoidance has not been achieved. PNI incidence according to fluoroscopy-guided PN monitoring, high-output pace-guided, compound motor action potential-guided, and 3-dimensional electro-anatomical mapping (EAM) systems was 8.1% (38/467), 2.7% (13/476), 2.4% (4/130), and 2.8% (11/389), respectively. However, a high-power, short-duration (50 W/7 s) radiofrequency (RF) energy application only on PNI risk points tagged by a 3-dimensional EAM system completely avoids PNI (0%; 0 /160 since April 2021). PNI showed no symptoms and recovered within an average of 188 days post-SVCI, except for a few patients who required > 1 year.

Conclusions

Although PNI incidence decreased annually with the introduction of various monitoring systems, these monitoring systems did not prevent PNI completely. Most notably, the delivery of a high-power, short-duration RF energy only on risk points tagged by EAM prevented PNI completely. PNI recovered in all patients. The application of higher-power, shorter-duration RF energy on risk points tagged by EAM appears to be an optimal PNI prevention maneuver.

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Data availability

The data that supports the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

PNI:

Phrenic nerve injury

HPSD:

High-power, short-duration

LPLD:

Low-power, long-duration

SVC:

Superior vena cava

SVCI:

Superior vena cava isolation

CA:

Catheter ablation

AF:

Atrial fibrillation

PV:

Pulmonary vein

PVI:

Pulmonary vein isolation

LA:

Left atrium

CMAP:

Compound motor action potential

3D:

Three-dimensional

EAM:

Electro-anatomical mapping

References

  1. Tsai CF, Tai CT, Hsieh MH, Lin WS, Yu WC, Ueng KC, et al. Initiation of atrial fibrillation by ectopic beats originating from the superior vena cava: electrophysiological characteristics and results of radiofrequency ablation. Circulation. 2000;102:67–74.

    Article  CAS  PubMed  Google Scholar 

  2. Shah D, Haissaguerre M, Jais P, Hocini M. Nonpulmonary vein foci: do they exist? Pacing Clin Electrophysiol. 2003;26:1631–5.

    Article  PubMed  Google Scholar 

  3. Miyazaki S, Takigawa M, Kusa S, Kuwahara T, Taniguchi H, Okubo K, et al. Role of arrhythmogenic superior vena cava on atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25:380–6.

    Article  PubMed  Google Scholar 

  4. Miyazaki S, Taniguchi H, Kusa S, Ichihara N, Nakamura H, Hachiya H, et al. Factors predicting an arrhythmogenic superior vena cava in atrial fibrillation ablation: insight into the mechanism. Heart Rhythm. 2014;11:1560–6.

    Article  PubMed  Google Scholar 

  5. Arruda M, Mlcochova H, Prasad SK, Kilicaslan F, Saliba W, Patel D, et al. Electrical isolation of the superior vena cava: an adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation. J Cardiovasc Electrophysiol. 2007;18:1261–6.

    Article  PubMed  Google Scholar 

  6. Corrado A, Bonso A, Madalosso M, Rossillo A, Themistoclakis S, Di Biase L, et al. Impact of systematic isolation of superior vena cava in addition to pulmonary vein antrum isolation on the outcome of paroxysmal, persistent, and permanent atrial fibrillation ablation: results from a randomized study. J Cardiovasc Electrophysiol. 2010;21:1–5.

    Article  PubMed  Google Scholar 

  7. Kang KW, Pak HN, Park J, Park JG, Uhm JS, Joung B, et al. Additional linear ablation from the superior vena cava to right atrial septum after pulmonary vein isolation improves the clinical outcome in patients with paroxysmal atrial fibrillation: prospective randomized study. Europace. 2014;16:1738–45.

    Article  PubMed  Google Scholar 

  8. Ejima K, Kato K, Iwanami Y, Henmi R, Yagishita D, Manaka T, et al. Impact of an empiric isolation of the superior vena cava in addition to circumferential pulmonary vein isolation on the outcome of paroxysmal atrial fibrillation ablation. Am J Cardiol. 2015;116:1711–6.

    Article  PubMed  Google Scholar 

  9. Li JY, Jiang JB, Zhong GQ, Ke HH, He Y. Comparison of empiric isolation and conventional isolation of superior vena cava in addition to pulmonary vein isolation on the outcome of paroxysmal atrial fibrillation ablation. Int Heart J. 2017;58:500–5.

    Article  PubMed  Google Scholar 

  10. Zhang T, Wang Y, Liang Z, Zhao H, Han Z, Wang Y, et al. Effect of combined pulmonary vein and superior vena cava isolation on the outcome of second catheter ablation for paroxysmal atrial fibrillation. Am J Cardiol. 2020;125:1845–50.

    Article  PubMed  Google Scholar 

  11. Omuro T, Yoshiga Y, Ueyama T, Shimizu A, Ono M, Fukuda M, et al. An impact of superior vena cava isolation in non-paroxysmal atrial fibrillation patients with low voltage areas. J Arrhythm. 2021;37:965–74.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Overeinder I, Osorio TG, Calburean PA, Bisignani A, Bala G, Sieira J, et al. Comparison between superior vena cava ablation in addition to pulmonary vein isolation and standard pulmonary vein isolation in patients with paroxysmal atrial fibrillation with the cryoballoon technique. J Interv Card Electrophysiol. 2021;62:579–86.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Chang HY, Lo LW, Lin YJ, Chang SL, Hu YF, Feng AN, et al. Long-term outcome of catheter ablation in patients with atrial fibrillation originating from the superior vena cava. J Cardiovasc Electrophysiol. 2012;23:955–61.

    Article  PubMed  Google Scholar 

  14. Knecht S, Zeljkovic I, Badertscher P, et al. Role of empirical isolation of the superior vena cava in patients with recurrence of atrial fibrillation after pulmonary vein isolatio—a multi-center analysis. J Interv Card Electrophysiol 2022 Aug 18. https://doi.org/10.1007/s10840-022-01314-w.

  15. Sanchez-Quintana D, Cabrera JA, Climent V, Farre J, Weiglein A, Ho SY. How close are the phrenic nerves to cardiac structures? Implications for cardiac interventionalists. J Cardiovasc Electrophysiol. 2005;16:309–13.

    Article  PubMed  Google Scholar 

  16. Sacher F, Monahan KH, Thomas SP, Davidson N, Adragao P, Sanders P, et al. Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study. J Am Coll Cardiol. 2006;47:2498–503.

    Article  PubMed  Google Scholar 

  17. Franceschi F, Dubuc M, Guerra PG, Khairy P. Phrenic nerve monitoring with diaphragmatic electromyography during cryoballoon ablation for atrial fibrillation: the first human application. Heart Rhythm. 2011;8:1068–71.

    Article  PubMed  Google Scholar 

  18. Murakami T, Yamaji H, Numa K, Kawamura H, Murakami M, Higashiya S, et al. Adaptive-servo ventilation combined with deep sedation is an effective strategy during pulmonary vein isolation. Europace. 2013;15:951–6.

    Article  PubMed  Google Scholar 

  19. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary. Europace. 2018;20:157–208.

    Article  PubMed  Google Scholar 

  20. Yamaji H, Murakami T, Hina K, Higashiya S, Kawamura H, Murakami M, et al. Usefulness of dabigatran etexilate as periprocedural anticoagulation therapy for atrial fibrillation ablation. Clin Drug Investig. 2013;33:409–18.

    Article  CAS  PubMed  Google Scholar 

  21. Goyal R, Gracia E, Fan R. The role of superior vena cava isolation in the management of atrial fibrillation. J Innov Card Rhythm Manag. 2017;8:2674–80.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics. 2012;32:E51-70.

    Article  PubMed  Google Scholar 

  23. Bhaskaran A, Chik W, Pouliopoulos J, Nalliah C, Qian P, Barry T, et al. Five seconds of 50–60 W radio frequency atrial ablations were transmural and safe: an in vitro mechanistic assessment and force-controlled in vivo validation. Europace. 2017;19:874–80.

    PubMed  Google Scholar 

  24. Kusa S, Hachiya H, Sato Y, Hara S, Ohya H, Miwa N, et al. Superior vena cava isolation with 50 W high power, short duration ablation strategy. J Cardiovasc Electrophysiol. 2021;32:1602–9.

    Article  PubMed  Google Scholar 

  25. Parikh V, Kowalski M. Comparison of phrenic nerve injury during atrial fibrillation ablation between different modalities, pathophysiology and management. J Atr Fibrillation. 2015;8:1314.

    PubMed  PubMed Central  Google Scholar 

  26. Bai R, Patel D, Di Biase L, Fahmy TS, Kozeluhova M, Prasad S, et al. Phrenic nerve injury after catheter ablation: should we worry about this complication? J Cardiovasc Electrophysiol. 2006;17:944–8.

    Article  PubMed  Google Scholar 

  27. Tripp HF, Bolton JW. Phrenic nerve injury following cardiac surgery: a review. J Card Surg. 1998;13:218–23.

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Heart Rhythm Center, Okayama Heart Clinic, Takeda 54-1, Naka-Ku, Okayama, 703-8251, Japan

    Hirosuke Yamaji, Shunichi Higashiya, Takashi Murakami, Hiroshi Kawamura, Masaaki Murakami, Shigeshi Kamikawa & Shozo Kusachi

  2. Department of Medical Technology, Okayama University Graduate School of Health Sciences, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan

    Shozo Kusachi

Authors
  1. Hirosuke Yamaji
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  2. Shunichi Higashiya
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  3. Takashi Murakami
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  4. Hiroshi Kawamura
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  5. Masaaki Murakami
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  6. Shigeshi Kamikawa
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  7. Shozo Kusachi
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Contributions

(1) Substantial contributions to the conception and design or to the acquisition, analysis, or interpretation of the data: H.Y., S.H., T.M, H.K., M.M., S.K., and S.K.

(2) Substantial contributions to the drafting of the articles or critical revision of important intellectual content: H.Y., H.K., S.H., and S.K.

(3) Final approval of the version to be published: all authors.

(4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved: H.Y., S.H., T.M, H.K., M.M., S.K., and S.K.

Corresponding author

Correspondence to Hirosuke Yamaji.

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Ethics approval

Our study complied with the principles of the Declaration of Helsinki and was approved by the Institutional Ethics Committee for Human Research of the Okayama Heart Clinic.

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Written informed consent for the use of data without personally identifiable information was obtained from all patients.

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This study did not reproduce any material from other sources.

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The authors declare no competing interests.

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Yamaji, H., Higashiya, S., Murakami, T. et al. Optimal prevention method of phrenic nerve injury in superior vena cava isolation: efficacy of high-power, short-duration radiofrequency energy application on the risk points. J Interv Card Electrophysiol 66, 1465–1475 (2023). https://doi.org/10.1007/s10840-022-01449-w

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