The Phrenic Nerve and Atrial Fibrillation Ablation Procedures

Abstract

Radiofrequency ablation is increasingly used as an option to optimally manage patients with symptomatic atrial fibrillation. Presently, ablationists strive to improve success rates, particularly with persistent atrial fibrillation, while simultaneously attempting to reduce complications. A well-recognized complication with atrial fibrillation ablation is injury to the phrenic nerve giving rise to diaphragmatic paresis and patient discomfort.Phrenic nerve damage may occur when performing common components of atrial fibrillation ablation including pulmonary and superior vena caval isolation. The challenge for ablationists is to successfully target the arrhythmogenic substrate while avoiding this complication. In order to do this, a thorough knowledge of phrenic nerve anatomy, points in the ablation procedure where nerve damage is more likely, and an understanding of the presently utilized techniques to avoid this complication is required. In addition, when this complication does arise, prompt recognition of its occurrence, knowledge of the natural history, and available methods for management are needed.In this review, we discuss the underlying anatomic principles, techniques of avoiding phrenic nerve damage, and presently available methods of diagnosing and managing this complication.

Catheter ablation of atrial fibrillation with a multi‐electrode radiofrequency balloon; first and early two centre experience in Europe

“…Therefore rigorous monitoring of phrenic nerve capture and early detection of changes to CMAP remains the cornerstone to mitigate the risk of PNI. A decrease in the CMAP amplitude is the earliest sign of detectable injury to the phrenic nerve, 18 and is easy to measure. Therefore, close monitoring is required from the start of RF delivery.…”

An Uncommon Focus of a Common Phenomenon: Superior Vena Cava Triggering Atrial Fibrillation

“…The most common complication involves injury to the right phrenic nerve, which courses in close proximity to the SVC. 4 Injury is typically observed during ablation of the posterolateral SVC. Although injury results in paralysis of the right hemidiaphragm, most patients will recover within a year.…”

Irreversible Electroporation Ablation for Atrial Fibrillation: Status and Challenges

“…Phrenic nerve palsy is another complication of PVI by using thermal ablation. [19] In 2015, van Driel et al [31] found no evidence of right phrenic nerve damage after intentionally targeted ablation using circular 200-J DC applications with good tissue contact inside the superior vena cava wall. Occasionally, transient nerve palsy was induced, but normal pacing was monitored from the superior vena cava 30 minutes and 3 to 13 weeks after ablation.…”

“…The phrenic nerves are located very close to the superior vena cava, right PVs, and LA appendage. Phrenic nerve palsy is another complication of PVI by using thermal ablation [19] . In 2015, van Driel et al [31] found no evidence of right phrenic nerve damage after intentionally targeted ablation using circular 200-J DC applications with good tissue contact inside the superior vena cava wall.…”

“…In a nationwide US study involving 93,801 RFA procedures from 2000 to 2010, the overall incidence of perioperative complications was 6.29%, and in-hospital mortality was 0.46%. [14] The most frequent and severe complications of RFA are: (1) stroke (due to thrombosis formation), [15] (2) pulmonary vein (PV) stenosis, [16] (3) cardiac tamponade, [17] (4) coronary artery injury, [18] (5) phrenic nerve injury, [19] and (6) atrio-esophageal fistula. [20] CB ablation has emerged as a valid alternative in recent years.…”