Mapping and localization of the left phrenic nerve during left atrial appendage electrical isolation to avoid inadvertent injury in patients undergoing catheter ablation of atrial fibrillation

Romero, Jorge; Lakkireddy, Dhanunjaya; Cerna, Luis; Díaz, Juan Carlos; Cerrud‐Rodriguez, Roberto; Grupposo, Vito; Rios, Saul; Chernobelsky, Elizabeth; Gabr, Mohamed; García, Mario J.; Biase, Luigi Di

doi:10.1016/j.hrthm.2019.10.020

Cited by 9 publications

(6 citation statements)

References 30 publications

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“…In terms of anatomy, the LPN passes over the LAA surface, 23 and LAA ablation increases the potential risk of LPN injury. Romero et al performed LPN mapping on 66 patients during the LAA ablation procedure and verified that around 74% of LPN travelled across the middle and far sections of the LAA, while only 4.5% were found at the LAA ostium.…”

Section: Discussionmentioning

confidence: 99%

Safety and efficacy of the second-generation cryoballoon for left atrial appendage electrical isolation in canines

Liu,

Li,

Zhao

et al. 2024

Europace

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Background and Aims Left atrial appendage electrical isolation (LAAEI) has demonstrated a significant enhancement in the success rate of atrial fibrillation (AF) ablation. Nevertheless, concerns persist about the safety of LAAEI, particularly regarding alterations in left atrial appendage (LAA) flow velocity and the potential risks of thrombus. This study aimed to assess the efficacy and safety of LAAEI, investigating changes in LAA flow velocity in canines. Methods The study comprised a total of ten canines. The LAAEI procedure used by a 23mm cryoballoon (CB) of the second generation was conducted at least 180 seconds. Intracardiac ultrasonography (ICE) was employed to quantify the velocity flow of the LAA both prior to and following LAAEI. Following a three-month period, subsequent evaluations were performed to assess the LAA velocity flow and the potential reconnection. Histopathological examination was conducted. Results LAAEI was effectively accomplished in all canines, resulting in a 100% acute success rate (10/10). The flow velocity in the LAA showed a notable reduction during LAAEI as compared to the values before the ablation procedure (53.12±5.89 cm/s vs 42.01±9.22 cm/s, P= 0.007). After the follow-up, reconnection was observed in four canines, leading to a success rate of LAAEI of 60% (6/10). The flow velocity in the LAA was consistently lower (53.12±5.89 cm/s vs 44.33±10.49 cm/s, P = 0.006), and no blood clot development was observed. The histopathological study indicated that there was consistent and complete injury to the LAA, affecting all layers of its wall. The injured tissue was subsequently replaced by fibrous tissue. Conclusion The feasibility of using cryoballoon ablation for LAAEI was confirmed in canines, leading to a significant reduction of LAA flow velocity after ablation. Some restoration of LAA flow velocity after ablation may be linked to the passive movement of the LAA and potential reconnecting. However, this conclusion is limited to animal study, more clinical data are needed to further illustrate the safety and accessiblity of LAAEI in humans.

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Section: Discussionmentioning

confidence: 99%

Safety and efficacy of the second-generation cryoballoon for left atrial appendage electrical isolation in canines

Liu,

Li,

Zhao

et al. 2024

Europace

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“…While the anterior course does not cross the LAA, the lateral PN course descends close to the apex of the LAA, and the inferior PN course passes with a close relationship to the roof of the LAA. Romero et al 13 found that the left PN can be captured within the LAA in 74% of cases and in only 4.5% at the proximal LAA or the LAA ostium. Huemer et al 14 demonstrated PNC by high‐output pacing (20 mA) in the ostial part of the LAA in 5% of patients.…”

Section: Discussionmentioning

confidence: 99%

“…For the patients with high and low output PN pacing, the resulting minimal distance between the modified ablation lesion and site of PNC was significantly smaller for high output PNC (median 8 [IQR 6-10], n = 15) than for additional low output PNC (12 [7][8][9][10][11][12][13][14][15][16] mm, n = 10, p = 0.012).…”

Section: Minimal Distance Between Pn Capture and Ablation Lesionmentioning

confidence: 99%

3D mapping of phrenic nerve course for radiofrequency pulmonary vein isolation

Bohnen

Weber

Minners

et al. 2022

Cardiovasc electrophysiol

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Introduction Phrenic nerve (PN) injury is a rare but severe complication of radiofrequency (RF) pulmonary vein isolation (PVI). The objective of this study was to characterize the typical intracardiac course of the PN with a three‐dimensional electroanatomic mapping system, to quantify the need for modification of the ablation trajectory to avoid delivering an ablation lesion on sites with PN capture, and to identify very circumscribed areas of common PNC on the routine ablation trajectory of a RF‐PVI, allowing fast and effective PN screening for everyday usage. Methods We enrolled 137 consecutive patients (63 ± 9 years, 64% men) undergoing PVI. A detailed high output (20 mA) pace‐mapping protocol was performed in the right (RA) and left atrium (LA) and adjacent vasculature. Results The right PN was most commonly captured in the superior vena cava at a lateral (50%) or posterolateral (23%) position before descending along the RA either straight (29%) or with a posterolateral bend (20%). In the LA, beginning deep within the right superior pulmonary vein (RSPV), the right PN is most frequently detectable anterolateral (31%), then descends to the lateral proximal RSPV (23%), and further towards the lateral antral region (15%) onto the medial LA wall (12%). To avoid delivering an ablation lesion on sites with PN capture, modification of ablation trajectory was necessary in 23% of cases, most commonly in the lateral RSPV antrum (81%). No PN injury occurred. Conclusion PN mapping frequently reveals the close proximity of the PN to the ablation trajectory during PVI, particularly in the lateral RSPV antrum. Routine PN pacing should be considered during RF PVI procedures.

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“…Therefore, it is crucial to monitor the left PN function by pacing from the left subclavian vein or using a CMC in the LAA to avoid this potential complication. Romero et al 82 has reported that mapping the left PN's location is feasible to prevent left PNP during LAAi using 3D mapping systems. They included 66 patients and highlighted that in their study, the left PN was found along the distal segment of the LAA in 27 patients (40.9%), the middle segment in 22 (33.3%), and the proximal segment in 3 (4.5%).…”

Section: Complications Of Laai Using Cbmentioning

confidence: 99%

“…Therefore, it is crucial to monitor the left PN function by pacing from the left subclavian vein or using a CMC in the LAA to avoid this potential complication. Romero et al 82 . has reported that mapping the left PN's location is feasible to prevent left PNP during LAAi using 3D mapping systems.…”

Section: Non‐pv Triggersmentioning

confidence: 99%

Cryoballoon ablation of non‐PV triggers in persistent atrial fibrillation

Çöteli,

Dural,

Yorgun

et al. 2023

Pacing Clinical Electrophis

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Cryoballoon‐based catheter ablation has emerged as an efficacious and safe therapeutic intervention for patients with paroxysmal atrial fibrillation (PAF). PAF is primarily associated with the triggers in the pulmonary vein (PV). However, persistent atrial fibrillation (PeAF) is a complex condition that involves changes in the atrial substrate and the presence of non‐PV triggers. Therefore, a comprehensive treatment approach is necessary for patients with PeAF. Utilizing a 3D electroanatomical map, the radiofrequency‐based ablation technique adeptly identifies and targets the atrial substrate and non‐PV triggers. On the other hand, the cryoballoon‐based AF ablation was initially designed for PV isolation. However, its single‐shot feature makes it a great choice for electrophysiologists looking to address non‐PV triggers. It is possible to target the left atrial appendage (LAA), superior vena cava (SVC), left atrial roof, and posterior wall using the apparatus's unique configuration and ablation abilities. This review focuses on the increasing literature regarding cryoballoon‐based methods for non‐PV trigger ablation. Specifically, it delves into the technical procedures used to isolate the LAA, SVC, and ablate the left atrial roof and posterior wall.

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Mapping and localization of the left phrenic nerve during left atrial appendage electrical isolation to avoid inadvertent injury in patients undergoing catheter ablation of atrial fibrillation

Cited by 9 publications

References 30 publications

Safety and efficacy of the second-generation cryoballoon for left atrial appendage electrical isolation in canines

Safety and efficacy of the second-generation cryoballoon for left atrial appendage electrical isolation in canines

3D mapping of phrenic nerve course for radiofrequency pulmonary vein isolation

Cryoballoon ablation of non‐PV triggers in persistent atrial fibrillation

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