Fluoroscopy of spontaneous breathing is more sensitive than phrenic nerve stimulation for detection of right phrenic nerve injury during cryoballoon ablation of atrial fibrillation.
BACKGROUND
Right phrenic nerve palsy (PNP) is a typical complication of cryoballoon ablation of the right-sided pulmonary veins (PVs). Phrenic nerve function can be monitored by palpating the abdomen during phrenic nerve pacing from the superior vena cava (SVC pacing) or by fluoroscopy of spontaneous breathing. We sought to compare the sensitivity of these 2 techniques during cryoballoon ablation for detection of PNP.


RESULTS
A total of 133 patients undergoing cryoballoon ablation were monitored with both SVC pacing and fluoroscopy of spontaneous breathing during ablation of the right superior PV. PNP occurred in 27/133 patients (20.0%). Most patients (89%) had spontaneous recovery of phrenic nerve function at the end of the procedure or on the following day. Three patients were discharged with persistent PNP. All PNP were detected first by fluoroscopic observation of diaphragm movement during spontaneous breathing, while diaphragm could still be stimulated by SVC pacing. In patients with no recovery until discharge, PNP occurred at a significantly earlier time (86 ± 34 seconds vs. 296 ± 159 seconds, P < 0.001). No recovery occurred in 2/4 patients who were ablated with a 23 mm cryoballoon as opposed to 1/23 patients with a 28 mm cryoballoon (P = 0.049).


CONCLUSIONS
Fluoroscopic assessment of diaphragm movement during spontaneous breathing is more sensitive for detection PNP as compared to SVC pacing. PNP as assessed by fluoroscopy is frequent (20.0%) and carries a high rate of recovery (89%) until discharge. Early onset of PNP and use of 23 mm cryoballoon are associated with PNP persisting beyond hospital discharge.
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Markus
M
Linhart
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Annika
A
Nielson
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
René P
RP
Andrié
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Erica L
EL
Mittmann-Braun
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Florian
F
Stöckigt
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Jens
J
Kreuz
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Georg
G
Nickenig
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Jan W
JW
Schrickel
Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn M.D, Bonn, Germany.
Lars M
LM
Lickfett
D000328:Adult; D000368:Aged; D059925:Anatomic Landmarks; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D003452:Cryosurgery / Q000009:adverse effects*; D003964:Diaphragm / Q000294:innervation*; D004558:Electric Stimulation; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D010173:Palpation; D010243:Paralysis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D010351:Patient Discharge; D059348:Peripheral Nerve Injuries / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D010791:Phrenic Nerve / Q000293:injuries* / Q000503:physiopathology / Q000601:surgery; D011237:Predictive Value of Tests; D011667:Pulmonary Veins / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D020127:Recovery of Function; D012119:Respiration; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
atrial fibrillation; catheter ablation; cryoballoon ablation; phrenic nerve injury; phrenic nerve stimulation