Protecting the right phrenic nerve during catheter ablation: Techniques and anatomical considerations

Intentional pneumothorax avoids collateral damage: Dynamic phrenic nerve mobilization through intrathoracic insufflation of carbon dioxide

“…11 Mechanical displacement of the phrenic nerve from the myocardium to minimize risk of injury is intuitive, with several subxyphoid pericardial approaches described, including (1) gauze packing with forceps, 12 (2) filling the pericardial space with saline and/or air, 9 and (3) a steerable sheath combined with an inflatable balloon or a steerable catheter. 4,13 However, these approaches are not uniformly successful at eliminating phrenic nerve capture, even when used in combination, 9,14 which was again demonstrated in our case. Notably, these approaches are challenging to employ, requiring frequent equipment adjustments or an outright change in approach.…”

Pulsed field ablation using a focal contact force catheter allowed successful ablation of a focal right atrial tachycardia in the proximity of the phrenic nerve

“…Up until now, the only way to ablate safely in this region was by protecting the phrenic nerve during the ablation procedure, which has been done by balloon inflation in the epicardial space or by creating an iatrogenic pneumothorax. 2 , 3 , 4 , 5 We believe that these kinds of complex procedures will become obsolete once PFA with a focal catheter becomes more available.…”

“…Multiple approaches to prevent phrenic nerve injury during ablation of FAT have been described, but these approaches are generally more invasive and therefore more prone to complications, and are not easy to implement in routine daily practice. 2 , 3 , 4 , 5 The problem with conventional energy sources used for ablation of FAT, being radiofrequency or cryothermal energy, is that they are thermal and nonselective to cardiac tissue, with the risk of affecting neighboring structures. Pulsed field energy ablation (PFA) is a novel ablation modality that is currently used as an alternative energy source for pulmonary vein isolation in atrial fibrillation to overcome the potential risks and harm done by conventional thermal energy sources.…”

Video-assisted thoracoscopic surgery to displace the phrenic nerve during endocardial ablation of right atrial tachycardia

“…When the area targeted for ablation overlaps the zone of phrenic nerve capture, several nonsurgical approaches have been proposed to displace the nerve and allow ablation. 7 , 8 These include epicardial catheter manipulation and balloon inflation. However, these techniques are limited by a high rate of complications, including pericardial bleeding, 3 and safer approaches are needed.…”