title: Anatomic predictors of phrenic nerve injury in the setting of pulmonary vein isolation using the 28-mm second-generation cryoballoon.
abstract: BACKGROUND
  Phrenic nerve injury (PNI) is the most frequently observed complication during pulmonary vein (PV) isolation using the second-generation cryoballoon.
  
  
  OBJECTIVE
  The purpose of this study was to analyze anatomic predictors based on preprocedural computed tomographic imaging data.
  
  
  METHODS
  Forty-one patients with PNI during the procedure and 123 age-, gender-, and body mass index-matched controls were included. A total of 343 right PVs were evaluated for axial/coronal orientation, ostial diameters with cross-sectional area, ovality index, and branching pattern. External angle between the right superior pulmonary vein (RSPV) and the anterolateral wall of the left atrium (LA) was measured (RSPV-LA angle). Distance from this vertex to the superior vena cava (SVC) was considered the RSPV-SVC distance.
  
  
  RESULTS
  For the RSPV, more anterosuperior orientation, larger dimensions, shorter RSPV-SVC distance, and more obtuse RSPV-LA angle (all P <.001) were associated with PNI on univariate analysis. Independent variables after multivariable analysis were RSPV-LA angle (odds ratio 1.03 per degree, 95% confidence interval 1.01-1.04, P <.001) and RSPV area (odds ratio 1.2 per mm², 95% confidence interval 1.1-1.3, P <.001), with a cutoff value ≥141° for RSPV-LA angle (91% sensitivity, 85% specificity) and ≥275 mm² for RSPV area (88% sensitivity, 85% specificity). RIPV area was an independent predictor for PNI at RIPV. A right-sided long common trunk was seen exclusively in 3 patients in the PNI group.
  
  
  CONCLUSIONS
  Preprocedural anatomic assessment of right PVs is useful in evaluating the risk of PNI. Ostial vein area and external RSPV-LA angle measurement showed excellent predictive value for PNI at the RSPV.
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium. Electronic address: strokerwin@gmail.com.
authors.forename: Erwin
authors.initials: E
authors.lastname: Ströker
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Carlo
authors.initials: C
authors.lastname: de Asmundis
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Yukio
authors.initials: Y
authors.lastname: Saitoh
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Vedran
authors.initials: V
authors.lastname: Velagić
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Mugnai
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Ghazala
authors.initials: G
authors.lastname: Irfan
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Burak
authors.initials: B
authors.lastname: Hünük
authors.affiliation: Radiology Department, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Kaoru
authors.initials: K
authors.lastname: Tanaka
authors.affiliation: Radiology Department, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Dries
authors.initials: D
authors.lastname: Belsack
authors.affiliation: Department of Biomedical Statistics and Informatics, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Ronald
authors.initials: R
authors.lastname: Buyl
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Pedro
authors.initials: P
authors.lastname: Brugada
authors.affiliation: Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium.
authors.forename: Gian-Battista
authors.initials: GB
authors.lastname: Chierchia
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D015992:Body Mass Index; D016022:Case-Control Studies; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D003452:Cryosurgery / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D059348:Peripheral Nerve Injuries / Q000209:etiology / Q000517:prevention & control; D010791:Phrenic Nerve / Q000293:injuries; D011237:Predictive Value of Tests; D011379:Prognosis; D011667:Pulmonary Veins / Q000000981:diagnostic imaging / Q000601:surgery; D012307:Risk Factors; D012737:Sex Factors; D014057:Tomography, X-Ray Computed / Q000379:methods
keywords: Ablation; Atrial fibrillation; Cryoballoon; Phrenic nerve injury; Pulmonary vein anatomy