Histopathology of Cryoballoon Ablation‐Induced Phrenic Nerve Injury

Andrade, Jason G.; Dubuc, Marc; Ferreira, José; Guerra, Peter G.; Landry, Evelyn; Coulombe, Nicolas; Rivard, Léna; Macle, Laurent; Thibault, Bernard; Talajic, Mario; Roy, Denis; Khairy, Paul

doi:10.1111/jce.12296

Cited by 60 publications

(44 citation statements)

References 15 publications

(52 reference statements)

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“…These techniques seem most useful in confirming established phrenic nerve injury because they are altered too late in the pathophysiological process to prevent nerve damage. 6 In contrast, real-time diaphragmatic electromyographic monitoring represents a potentially more sensitive tool for detecting early changes to phrenic nerve function. 4,6 Specifically, during phrenic nerve pacing a reproducible supramaximal hemidiaphragmatic CMAP can be reliably recorded using surface electrodes, providing valuable information about phrenic nerve function.…”

Section: Diaphragmatic Cmap During Cryoballoon Ablationmentioning

confidence: 99%

“…In a recent preclinical studies, we demonstrated that a 30% reduction in diaphragmatic CMAP amplitude presaged impending hemidiaphragmatic paralysis by ≈30 seconds. 4,6 Herein, we characterize our clinical experience using diaphragmatic electromyographic monitoring for the prevention of PNP.…”

mentioning

confidence: 99%

“…Although alternative monitoring techniques, such as continuous diaphragmatic visualization and auditory monitoring of diaphragmatic contraction have been proposed, the use of diaphragmatic electromyography represents a potentially more sensitive technique for detecting early changes to the phrenic nerve. 4,6 During phrenic nerve pacing a reliable diaphragmatic signal (the diaphragmatic compound motor action potential [CMAP]) can be easily recorded using surface electrodes, providing valuable information about phrenic nerve function. In a recent preclinical studies, we demonstrated that a 30% reduction in diaphragmatic CMAP amplitude presaged impending hemidiaphragmatic paralysis by ≈30 seconds.…”

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confidence: 99%

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Clinical Experience With a Novel Electromyographic Approach to Preventing Phrenic Nerve Injury During Cryoballoon Ablation in Atrial Fibrillation

Mondésert

Andrade

Khairy

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-Phrenic nerve palsy remains the most frequent complication associated with cryoballoon-based pulmonary vein (PV) isolation. We sought to characterize our experience using a novel monitoring technique for the prevention of phrenic nerve palsy. Methods and Results-Two hundred consecutive cryoballoon-based PV isolation procedures between October 2010and October 2013 were studied. In addition to standard abdominal palpation during right phrenic nerve pacing from the superior vena cava, all patients underwent diaphragmatic electromyographic monitoring using surface electrodes. Cryoablation was terminated on any perceived reduction in diaphragmatic motion or a 30% decrease in the compound motor action potential (CMAP). During right-sided ablation, a ≥30% reduction in CMAP amplitude occurred in 49 patients (24.5%). Diaphragmatic motion decreased in 30 of 49 patients and was preceded by a 30% reduction in CMAP amplitude in all. In 82% of cases, this reduction in CMAP amplitude occurred during right superior PV isolation. The baseline CMAP amplitude was 946.5±609.2 mV and decreased by 13.8±13.8% at the end of application. This decrease was more marked in the 33 PVs with a reduction in diaphragmatic motion than in those without (40.9±15.3% versus 11.3±10.5%; P<0.001). In 3 cases, phrenic nerve palsy persisted beyond the end of the procedure, with all cases recovering within 6 months. Despite the shortened application all veins were isolated. At repeat procedure the right-sided PVs reconnected less frequently than the left-sided PVs in those with phrenic nerve palsy. Conclusions-Electromyographic phrenic nerve monitoring using the surface CMAP is reliable, easy to perform, and offers an early warning to impending phrenic nerve injury. (Circ Arrhythm Electrophysiol. 2014;7:605-611.)

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Section: Diaphragmatic Cmap During Cryoballoon Ablationmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Clinical Experience With a Novel Electromyographic Approach to Preventing Phrenic Nerve Injury During Cryoballoon Ablation in Atrial Fibrillation

Mondésert

Andrade

Khairy

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…The study by Guhl et al 40 systematically demonstrated an increased risk for phrenic nerve injury with the use of the 23-mm cryoballoon as well as with advanced age. The injury was transient for the majority of their cohort, and they noted that recommendations of monitoring diaphragmatic electromyographic signals with compound motor action potential [41][42][43][44][45] and rapid balloon deflation or double deflation leading to a more rapid tissue warming may reduce the extent of phrenic nerve injury. 46 The study by Mugnai et al 47 reported that the overall complication rate using second-generation cryoballoon PVI was 2%, with vascular access being a frequent major complication.…”

Section: S T Mathew and S S Pomentioning

confidence: 99%

Atrial Fibrillation Catheter Ablation: Overcoming Complications and Improving Success

Mathew

2017

J Innov Cardiac Rhythm Manage

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ABSTRACT. Careful patient selection and optimization of the management of active medical conditions prior to proceeding with catheter ablation for atrial fibrillation (AF) is critical to reducing complications and improving ablation success. AF ablation performed on patients who have not been offered appropriate antiarrhythmic drug therapy must be tempered with the procedure risks, particularly for those patients having multiple comorbidities. The inability to comply with systemic anticoagulation for thromboembolic prophylaxis in AF is a contraindication to AF ablation, as premature termination of anticoagulation therapy can lead to catastrophic thromboembolic complications. Successful pulmonary vein isolation (PVI), the cornerstone of AF ablation, is demonstrated by entrance and exit block post ablation, with sustained absence of atrium-to-pulmonary vein conduction in both directions. Beyond PVI, there is no consensus for other endpoints for AF ablation, particularly in patients with persistent or longstanding persistent AF. Complications of PVI for AF have decreased in recent years as technology and knowledge in this field has evolved; however, the risks of cardiac tamponade, thromboembolic complications, esophageal injury, and pulmonary vein stenosis may still be formidable.

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“…In the past decade, catheter ablation of AF has evolved from an investigational procedure to a frequent therapeutic one (2). Phrenic nerve injury (PNI) is a complication of ablation that pulmonologists should be familiar with, due to its increasing incidence (3). This condition can mimic that of comorbid conditions like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).…”

Section: Introductionmentioning

confidence: 99%

Phrenic nerve injury post catheter ablation for atrial fibrillation

Sen¹,

Majumdar²,

Saeed³

2018

Southwest J Pulm Crit Care

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Objective: Phrenic nerve injury (PNI) is a complication of catheter ablation treatment of atrial fibrillation (AF). This condition can mimic that of comorbid conditions like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Case details: A 77-year-old woman with past medical history of heart failure with preserved ejection fraction and mild COPD, presented with dyspnea for 8 days. One week ago, she had undergone radiofrequency catheter ablation for persistent symptomatic AF. After the ablation, she reported dyspnea during PCP and pulmonary office visits and was given increasing doses of diuretics and inhalers since her symptoms were attributed to acute exacerbation of heart failure in the setting of COPD. However, a chest x-ray showed elevation of the right hemidiaphragm, and she had a positive sniff test. She was thus diagnosed with right sided phrenic nerve palsy and was treated with oxygen therapy.

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Histopathology of Cryoballoon Ablation‐Induced Phrenic Nerve Injury

Abstract: Phrenic nerve injury induced by cryoballoon ablation is axonal in nature and characterized by Wallerian degeneration, with potential for recovery. An EMG-guided approach is superior to standard monitoring in limiting phrenic nerve damage.

Cited by 60 publications

References 15 publications

Clinical Experience With a Novel Electromyographic Approach to Preventing Phrenic Nerve Injury During Cryoballoon Ablation in Atrial Fibrillation

Clinical Experience With a Novel Electromyographic Approach to Preventing Phrenic Nerve Injury During Cryoballoon Ablation in Atrial Fibrillation

Atrial Fibrillation Catheter Ablation: Overcoming Complications and Improving Success

Phrenic nerve injury post catheter ablation for atrial fibrillation

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