Anatomic evaluation of the left phrenic nerve relevant to epicardial and endocardial catheter ablation: Implications for phrenic nerve injury

Sánchez‐Quintana, Damián; Ho, Siew Yen; Climent, Vicente; Murillo, Margarita; Cabrera, José Ángel

doi:10.1016/j.hrthm.2009.02.029

Cited by 80 publications

(53 citation statements)

References 21 publications

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“…Prompt removal of infected devices ensures survival [1][2][3][4]. We report successful extraction of a lead from an infected CIED by using an excimer laser system.…”

Section: Clinical Casementioning

confidence: 98%

Successful transjugular extraction of a lead in front of the anterior scalene muscle by using snare technique

Okada

Aizawa

Tomita

et al. 2015

Journal of Arrhythmia

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a b s t r a c tThe incidence of cardiovascular implantable electronic device infection is increasing. We report a case of and successful device removal in a 79-year-old man with implantable cardioverter-defibrillator infection. Right phrenic nerve paralysis was evident on chest radiography. The lead was in front of the anterior scalene muscle, close to the left phrenic nerve. Therefore, extraction carried a risk of bilateral phrenic nerve paralysis. The lead was successfully extracted from the right internal jugular vein by using the snare technique. No complications occurred, and the extraction was successful.

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“…Prompt removal of infected devices ensures survival [1][2][3][4]. We report successful extraction of a lead from an infected CIED by using an excimer laser system.…”

Section: Clinical Casementioning

confidence: 98%

Successful transjugular extraction of a lead in front of the anterior scalene muscle by using snare technique

Okada

Aizawa

Tomita

et al. 2015

Journal of Arrhythmia

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“…23 Our study on cadavers found the course of the left phrenic nerve and its accompanying pericardiophrenic vessels in the fibrous pericardium that was overlying the atrial appendage in majority of cases. 53 The esophagus, though useful as a portal for echocardiographic imaging, is at risk of damage during left atrial ablation procedures. Understanding the course of the esophagus is essential to reduce the risk of atrio-esophageal fistula after catheter ablation on the posterior wall.…”

Section: Interatrial Muscular Connectionsmentioning

confidence: 99%

“…The left phrenic nerve takes an anterior (18%), lateral (59%), or posteroinferior (23%) course on the fibrous pericardium overlying the left heart. 53 The lateral course passes over the tip of the left atrial appendage, whereas the posteroinferior course passes over the roof of the appendage os.…”

Section: Interatrial Muscular Connectionsmentioning

confidence: 99%

Left Atrial Anatomy Revisited

Cabrera²,

Sánchez‐Quintana³

2012

Circ: Arrhythmia and Electrophysiology

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296

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R ecent decades have seen rapid developments in arrhythmia treatment, especially the use of catheter ablation. Although the substrates of atrial fibrillation, its initiation and maintenance, remain to be fully elucidated, catheter ablation in the left atrium has become a therapeutic option for patients with this arrhythmia. With ablation techniques, various isolation lines and focal targets are deployed; the majority of these are anatomic approaches. It has been over a decade since we published our first article on the anatomy of the left atrium relevant to interventional electrophysiologists. 1 Our aim then, as now, was to increase awareness of anatomic structures inside the left atrium. In this review of anatomy, we revisit the left atrium, inside as well as outside, for a better understanding of the atrial component parts and the spatial relationships of specific structures. Location and Atrial WallsViewed from the frontal aspect of the chest, the left atrium is the most posteriorly situated of the cardiac chambers. Owing to the obliquity of the plane of the atrial septum and the different levels of the orifices of the mitral and tricuspid valves, the left atrial chamber is more posteriorly and superiorly situated relative to the right atrial chamber. The pulmonary veins enter the posterior part of the left atrium with the left veins located more superior than the right veins. The transverse pericardial sinus lies anterior to the left atrium, and in front of the sinus is the root of the aorta. The tracheal bifurcation, the esophagus, and descending thoracic aorta are immediately behind the pericardium overlying the posterior wall of the left atrium. Further behind is the vertebral column.Following the direction of blood flow, the atrial chamber begins at the pulmonary veno-atrial junctions and terminates at the fibro-fatty tissue plane that marks the atrioventricular junction at the mitral orifice. The walls of the left atrium are muscular and can be described as superior, posterior, left lateral, septal (or medial), and anterior, as suggested by McAlpine, 2 who drew attention to the importance of describing the heart in its anatomic position in the chest, in the orientation he termed "attitudinal," which is the appropriate terminology for cardiac interventionists. 3 The left atrium is relatively smooth-walled on its internal aspect ( Figure 1A), but its walls are not uniform in thickness. The roof or superior wall is in close proximity to the bifurcation of the pulmonary trunk and the right pulmonary artery. The thickness of its muscle component measured transmurally ranges from 3.5 to 6.5 mm (mean, 4.5Ϯ0.6 mm) in formalin-fixed heart specimens. 4 The thickness of the lateral wall ranges between 2.5 and 4.9 mm (mean, 3.9Ϯ0.7 mm). The anterior wall, related to the aortic root, ranges from 1.5 to 4.8 mm (mean, 3.3Ϯ1.2 mm) thick, but it can become very thin at the area near the vestibule ( Figure 1B) of the mitral annulus, diminishing to an average thickness of 2 mm. Importantly, there is an area of the anterio...

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“…Cryoballoon freeze was limited to 180 s, reaching a minimal temperature of −57°C. The left phrenic nerve, because of its proximity to the LAA, 1 was monitored by fluoroscopy during spontaneous breathing. After further conventional CB2 PV isolation, total procedure-and fluoroscopy-time were 70 and 12.0 min, respectively.…”

Section: Case Descriptionmentioning

confidence: 99%

Durable Single Shot Cryoballoon Isolation of the Left Atrial Appendage Followed by Percutaneous Left Atrial Appendage Closure

Bordignon

Perrotta

Fürnkranz

et al. 2015

Circ: Arrhythmia and Electrophysiology

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A 73-year-old paroxysmal atrial fibrillation (AF) male patient (CHADSVASC, 3; HASBLED, 3) was referred to our center for staged AF ablation and left atrial appendage (LAA) closure. Previously, the patient had experienced gastric bleeding on Apixaban. Therefore, we agreed with the patient on additional LAA isolation during AF ablation if electric triggers from the LAA were present. After a single transseptal puncture, selective pulmonary veins (PVs) and LAA angiographies were performed. The 28 mm second generation cyroballoon (CB2; Arctic Front Advance, Medtronic, USA) was advanced into the left atrium. The inner lumen circumferential multipolar catheter (Achieve 20 mm, Medtronic, USA) demonstrated automatic activity in the LAA. Therefore, the CB2 was inflated and positioned at the LAA ostium aiming for complete occlusion ( Figure A). During CB ablation, progressive LAA spike delay resulted in LAA isolation (time to block, 73 s; CB temperature, −48°C; Figure B). Cryoballoon freeze was limited to 180 s, reaching a minimal temperature of −57°C. The left phrenic nerve, because of its proximity to the LAA, 1 was monitored by fluoroscopy during spontaneous breathing. After further conventional CB2 PV isolation, total procedure-and fluoroscopy-time were 70 and 12.0 min, respectively. Interestingly, transesophageal echo demonstrated a substantial ablation-induced acute edema of the LAA-PV ridge (Figure C and D). Discharged on low molecular weight heparin (enoxaparin 0.8 mL twice a day), the patient was rescheduled for elective percutaneous LAA closure after 6 weeks. During the LAA closure procedure, a 15 mm spiral catheter (Lasso, Biosense Webster) confirmed permanent LAA isolation (entrance+exit block; Figure E). The postablation LAA-PV ridge edema resolved, and a 24 mm Watchman (Boston Scientific, USA) device could be implanted without any residual LAA flow or procedural complications ( Figure F). The low molecular weight heparin was discontinued and substituted by dual antiplatelet therapy (aspirin/clopidogrel) for additional 6 weeks. DiscussionAtrial appendages have been identified as sources of atrial arrhythmias.2 The LAA has been considered an additional AF trigger site beyond the PVs 3 and termed the 5th PV. LAA isolation using point-by-point radiofrequency current ablation is feasible, but there are safety concerns about ablating at the LAA ostium. To best of our knowledge, this case is the first description of single shot LAA isolation using the 28 mm CB2. Relevant findings include (1) safe LAA mapping using the intraluminal soft tip circumferential multipolar catheter, (2) straightforward LAA isolation and visualization of time to effect, and (3) proof of permanency of CB LAA isolation. These initial observations may point toward an additional anatomic target during CB AF ablation in selected patients. In our patient, we decided to perform a staged AF ablation procedure, including LAA isolation (because of spontaneous electric activity originating from the LAA as described by DiBiase et al 2 ), followed by LA...

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Anatomic evaluation of the left phrenic nerve relevant to epicardial and endocardial catheter ablation: Implications for phrenic nerve injury

Cited by 80 publications

References 21 publications

Successful transjugular extraction of a lead in front of the anterior scalene muscle by using snare technique

Successful transjugular extraction of a lead in front of the anterior scalene muscle by using snare technique

Left Atrial Anatomy Revisited

Durable Single Shot Cryoballoon Isolation of the Left Atrial Appendage Followed by Percutaneous Left Atrial Appendage Closure

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