Left phrenic nerve injury during electrical isolation of left-sided pulmonary veins with the second-generation cryoballoon.

Abstract

Phrenic nerve (PN) palsy (PNP) is the most frequent complication of cryoballoon ablation (CBA) of atrial fibrillation (AF). The major complication of this technique seems to be right-sided PN injury (PNI) following ablation of the right pulmonary veins (PVs). We sought to assess the incidence and prognosis of left-sided PNI during CBA. CBA was performed in 448 patients with AF. During the ablation of the left-sided PVs, the PN was paced from the left subclavian vein with a pacing output just exceeding the threshold by 10 ∼ 20%. The right and left arm 12-lead electrocardiogram electrodes were positioned 5 cm above the xiphoid process and 16 cm along the left costal margin. The amplitude of the compound motor action potentials was recorded during the CBA. Two thousand one hundred seventy-eight CBA applications were delivered in 1,094 left-sided PVs. PNI occurred in 29 patients (6.5%); the PN could be captured by an increasing pacing output in 21 patients (4.7%), and premature termination of the freezing was required to avoid PNP in eight patients (1.8%). The PN function recovered before discharge; however, it took 7 months for one patient to completely recovery from the PNP. Left-sided PNP could be provoked during a left-sided CBA procedure. Assessment of the left PN during the CBA was necessary to prevent left-sided PNP.