Phrenic Nerve Palsy Research Articles

Cryoballoon ablation of atrial fibrillation in patients with atypical right pulmonary vein anatomy

Cryoballoon ablation is widely used for pulmonary vein isolation in patients with atrial fibrillation. There are no data regarding the clinical efficacy of cryoballoon ablation in patients with atypical right pulmonary vein anatomy. We aimed to evaluate the impact of right pulmonary vein anatomy on the safety and efficacy of cryoballoon ablation. Patients referred for cryoballoon ablation of paroxysmal atrial fibrillation were enrolled prospectively. Left atrial computed tomography was performed before cryoballoon ablation to determine whether the right pulmonary vein anatomy was "normal" or "atypical". For patients with atypical anatomy, cryoballoon ablation was only performed for right superior and right inferior pulmonary veins, neglecting accessory pulmonary veins. Overall, 303 patients were included: 254 (83.8%) with normal and 49 (16.2%) with atypical right pulmonary vein anatomy. First-freeze isolation for right superior and right inferior pulmonary veins occurred in 44 (89.8%) and 37 (75.5%) patients with atypical pulmonary vein anatomy, and in 218 (85.8%) and 217 (85.4%) patients with typical pulmonary vein anatomy, respectively (P not significant). Phrenic nerve palsies were only observed in patients with normal anatomy (0 vs. 26 [8.6%]; P=0.039). Mid-term survival free from atrial arrhythmia was similar, regardless of right pulmonary vein anatomy. A significant proportion of patients have atypical right pulmonary vein anatomy. Procedural characteristics, acute pulmonary vein isolation success and mid-term procedural efficacy were similar, regardless of right pulmonary vein anatomy. In addition to left-side pulmonary vein isolation, cryoballoon ablation of right superior and right inferior pulmonary veins only, neglecting accessory pulmonary veins, is sufficient to obtain acute right-side pulmonary vein isolation and mid-term sinus rhythm maintenance in patients with atypical anatomy.

Cool enough? Lessons learned from cryoballoon-guided catheter ablation for atrial fibrillation in young adults.

Cryoballoon (CB)-guided ablation of atrial fibrillation (AF) is established in symptomatic AF patients. This study sought to determine the safety and efficacy of CB pulmonary vein isolation (PVI) in young adults. A total of 93 consecutive patients aged <45 years referred to our center for AF ablation were included in this observational study. All patients received CB-guided PVI according to a standardized institutional protocol. Follow-up was performed in our outpatient clinic using 72-h Holter monitoring and periodic telephone interview. Recurrence was defined as any AF/atrial tachycardia (AT) episode >30 s following a 3-month blanking period. A propensity matched control group consisting of patients older than 45 years were used for further evaluation. Mean age was 35 ± 7 years, 22% suffered from persistent AF, 85% were male. Mean follow-up was 2.6 ± 2 years. At the end of the observational period, 83% of patients were free of any AF/AT episodes. There was an excellent overall 12-month success rate of 92%. In comparison to a matched group the overall recurrence rate was noticeably lower in the young group (15% vs. 27%). Increasing age was associated with a hazard ratio of 1.16 for recurrence. In a multivariate analysis model, left atrial diameter remained as significant predictor of AF/AT recurrence. The complication rate was low, no permanent phrenic nerve palsy was observed. CB-guided PVI in young adults is safe and effective with favorable long-term results. It may be considered as first-line therapy in this relatively healthy population.

Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic.

Given that COVID-19 can severely impair lung function, regional anesthesia techniques avoiding phrenic nerve paralysis are relevant in the anesthetic management of suspected/confirmed COVID-19 patients requiring shoulder and clavicle surgical procedures. The objective of this review is to provide an overview of recently published studies examining ultrasound-guided diaphragm-sparing regional anesthesia techniques for the brachial plexus (BP) to favor their preferent use in patients at risk of respiratory function compromise. In the last 18 months, study findings on various diaphragm-sparing regional anesthesia techniques have demonstrated comparable block analgesic effectivity with a variable extent of phrenic nerve paralysis. The impact of hemi-diaphragmatic function impairment on clinical outcomes is yet to be established. Existing diaphragm-sparing brachial plexus regional anesthesia techniques used for shoulder and clavicle surgery may help minimize pulmonary complications by preserving lung function, especially in patients prone to respiratory compromise. Used as an anesthetic technique, they can reduce the risk of exposure of healthcare teams to aerosol-generating medical procedures (AGMPs), albeit posing an increased risk for hemi-diaphragmatic paralysis. Reducing the incidence of phrenic nerve involvement and obtaining opioid-sparing analgesia without jeopardizing efficacy should be prioritized goals of regional anesthesia practice during the COVID-19 pandemic.

Feasibility and Safety of Laparoscopic-Guided Epicardial Access for Ventricular Tachycardia Ablation.

BackgroundThe usual approach to epicardial access in patients with Chagas cardiomyopathy and megacolon is surgical access to avoid bowel injury. However, there are concerns regarding its safety in cases of Chagas cardiomyopathy with reports of prolonged mechanical ventilation and high mortality in this clinical setting. The aim of this study was to examine feasibility and complication rates for ventricular tachycardia ablation performed with laparoscopic‐guided epicardial access.Methods and ResultsThis single center study examined complication rates of the first 11 cases of ventricular tachycardia ablation in patients with Chagas cardiomyopathy, using laparoscopic guidance to access epicardial space. All 11 patients underwent epicardial VT ablation using laparoscopic‐guided epicardial access, and the complication rates were compared with historical medical reports. The main demographic features of our population were age, 63±13 years; men, 82%; and median ejection fraction, 31% (Q1=30% and Q3=46%). All patients were sent for ventricular tachycardia ablation because of medical therapy failure. The reason for laparoscopy was megacolon in 10 patients and massive liver enlargement in 1 patient. Epicardial access was achieved in all patients. Complications included 1 severe cardiogenic shock and 1 phrenic nerve paralysis. No intra‐abdominal organ injury occurred; only 1 death, which was caused by progressive heart failure, was reported more than 1 month after the procedure.ConclusionsLaparoscopic‐guided epicardial access in the setting of ventricular tachycardia ablation and enlarged intra‐abdominal organ is a simple alternative to more complex surgical access and can be performed with low complication rates.

A systematic review and meta-analysis comparing second-generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation.

Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the preferred modalities for catheter ablation of atrial fibrillation (AF). Technological advances have improved procedural outcomes, warranting an updated comparison. We sought to evaluate the efficacy and safety of CBA-2nd generation (CBA-2G) in comparison to RFA-contact force (RFA-CF) in patients with AF. MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 03/01/2020 for relevant studies comparing CBA-2G versus RFA-CF in patients undergoing initial catheter ablation for AF. A total of 17 studies, involving 11 793 patients were included. There was no difference between the two groups in the outcomes of freedom from atrial arrhythmia (p = .67) and total procedural complications (p = .65). There was a higher incidence of phrenic nerve palsy in CBA-2G (odds ratio: 10.7; 95% confidence interval [CI]: 5.85 to 19.55;p < .001). Procedure duration was shorter (mean difference:-31.32 min; 95% CI:-40.73 to -21.92; p < .001) and fluoroscopy duration was longer (+3.21 min; 95% CI: 1.09 to 5.33; p = .003) in CBA-2G compared to RFA-CF. In the subgroup analyses of patients with persistent AF and>1 freeze lesion delivered per vein, there was no difference in freedom from atrial arrhythmia. In AF patients undergoing initial ablation, CBA-2G and RFA-CF were equally efficacious. The procedure duration was shorter, but with a higher incidence of phrenic nerve palsy in CBA-2G. In patients with persistent AF, there was no difference in the efficacy between CBA-2G or RFA-CF techniques.

Is the pleating technique superior to the invaginating technique for plication of diaphragmatic eventration in infants?

BackgroundsThe pleating technique is widely used in plication but is difficult to perform with thoracoscopy because of its complex procedure and the limited surgical space. Thus, the invaginating technique was introduced to facilitate thoracoscopic surgery and is now widely used in video-assisted thoracoscopic surgery (VATS) plication. However, the usefulness of the invaginating technique in children has not been established because of the lack of data on long-term outcomes after surgery using the technique. MethodsFrom March 2007 to December 2017, 21 patients who were surgically treated for congenital diaphragmatic eventration and phrenic nerve palsy after congenital cardiac surgery were divided into 2 groups according to the surgical method used (pleating technique: 10 patients, invaginating technique: 11 patients). We evaluated the patients for postoperative outcomes and recurrence of diaphragmatic eventration over 5 years. Postoperative recurrence of diaphragmatic eventration was confirmed by calculating the ratio of the eventration level between the eventrated and normal diaphragms. ResultsIn the 21 patients who underwent diaphragmatic plication, the pleating and invaginating techniques were used in 10 and 11 patients, respectively. The mean follow-up duration was 63.4 ± 48.4 months (pleating group [P] vs invaginating group [I]: 89.1 ± 52.4 vs 40.1 ± 30.8 months, p = 0.022). The mean eventration rates in the 21 patients was 26.7% ± 9.1% (P vs I: 26.6% ± 6.1% vs 26.9% ± 11.3%, p = 0.945) before operation and −2.1% ± 7.3% (−2.8% ± 7.5% vs −1.5% ± 7.4%, p = 0.695) in the immediate postoperative period. From the first to the fifth postoperative year, no recurrence of diaphragmatic eventration was found in any of the groups during the follow-up. ConclusionsThe invaginating technique was easier to perform but showed a similar long-term result as compared with the pleating technique in terms of the growth and development of the chest cavity in the pediatric patients in this study. Thus, we recommend that the invaginating technique be applied in VATS plication for children as an alternative to the pleating technique. Level of evidenceLevel III.

Subomohyoid-Suprascapular versus Interscalene Block: Comment.

While we welcome research into regional anesthesia in order to improve the quality of our medical provision, the study by Abdallah et al. demonstrates highly relevant problems in research in this area.1 First, the authors describe the interscalene block as one that poses dangers to certain populations. This may be true for a minority of patients such as those with severe respiratory impairment, but the vast majority of patients are not restricted by any ensuing respiratory compromise. Studies of healthy patients demonstrate that the phrenic nerve palsy is of no clinical relevance.2 Given that 2.5 yr in three hospitals were required to obtain the 136 patients in this study, there does not appear to be a large group of patients likely to benefit from a new block.It has to be realized that regional anesthesia provision remains far from universal. Although the interscalene technique has been around for many years and refined with the use of ultrasound, a recent Canadian study demonstrated that only around half of shoulder surgery patients were receiving a nerve block for ambulatory surgery.3 This is likely much lower in many other health systems. One of the reasons for this is likely a lack of training and confidence of anesthesia providers in performing the block; lack of resources also contributes. Refining blocks further, and in effect making them more difficult, is unlikely to benefit the population as a whole. It needs to become a more significant priority in the provision of regional anesthesia that basic blocks are able to be performed competently by more anesthesiologists rather than the ever increasing number of new blocks with small, unclear benefits.Support was provided solely from institutional and/or departmental sources.The authors declare no competing interests.

Association of chest tube position with phrenic nerve palsy after neonatal and infant cardiac surgery

BackgroundDiaphragm paralysis (DP) complicates the postoperative course of neonates and infants undergoing cardiac surgery. Events causing DP remain poorly understood, and preventive strategies remain elusive. This retrospective cohort analysis aims to test the hypothesis that chest tubes in contact with the phrenic nerve in the pleural apex may cause pressure palsy. MethodsIn late 2018, the chest tube positioning strategy was changed so as to avoid a putative “danger zone” configuration, defined as (1) the chest tube looping apicomedially at the level of the second right intercostal space, and (2) wedging of chest tube tip against pericardium. A preintervention and postintervention analysis of 531 patients from 2012 to 2019 was performed to evaluate any association of chest tube position or duration in place with DP. Univariable and multivariable analyses were carried out, with significance set a priori at P < .05. ResultsThe preintervention group comprised 488 patients, of whom 32 (6.6%) had RDP. The postintervention group comprised 43 patients, none of whom had DP. Multivariable analysis of the entire cohort revealed chest tube positioning in the danger zone as the only significant association with RDP (odds ratio, 4.22; 95% confidence interval, 1.57-11.33; P < .05). ConclusionsChest tubes that occupy the right superior pleural space are associated with increased risk of DP.

Heart rupture repair during huge mediastinal mass resection \u2013 case report

BackgroundVentricular rupture is rarely described in the literature outside the context of myocardial infarction, infection or neoplasm. It is associated with a high mortality rate due to late presentation and delayed surgical intervention, which involves sutureless or sutured techniques. Comprehensive literature review failed to identify any case of intra-operative right ventricular heart rupture followed by myocardial repair and a complete recovery after a prolonged intensive care unit (ICU) stay.Case presentationA 57-year-old previously healthy gentleman presented complaining of a new onset shortness of breath for 2 months. A large mediastinal mass was found on chest imaging and biopsy revealed a thymoma. Patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy then sternotomy and thymectomy en bloc with anterior pericardium. Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation. He was sent back to theatre, aggressive fluid resuscitation continued, surgical site exploration was done by reopening the sternum, and the bleeding source was identified and controlled, but intraoperative asystole developed. During internal cardiac massage, the right ventricle ruptured with a 3 cm defect which was successfully repaired using a pericardial patch without a bypass machine due to unavailability at our cancer center. The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months due to bilateral phrenic nerve paralysis, was discharged from ICU to the surgical floor 66 days after the operation and weaned off ventilator support after 85 days, adequate respiratory and physical rehabilitation followed. Patient is doing very well now with excellent performance, and free of tumor recurrence 30 months after surgery.ConclusionRight ventricular rupture is rarely described outside the context of myocardial infarction and valvular heart disease. Tumor proximity to the heart and neoadjuvant cardiotoxic chemotherapy are the proposed causes for precipitating the cardiac rupture in our case. Post-surgical patients who receive early physical rehabilitation and respiratory physiotherapy have improved survival and outcome.

Trapdoor anterior thoracotomy for cervicothoracic and apical thoracic neuroblastoma in children.

Cervicothoracic and apical thoracic neuroblastoma pose unique surgical challenges. We report our experience with the trapdoor anterior thoracotomy (TAT) approach to overcome these difficulties. Retrospective review of our centre's neuroblastoma database was conducted. Patients who underwent TAT at our centre were included, their demographic data and clinical reports were analyzed. A total of 21 patients underwent TAT for neuroblastoma, mean age at surgery of 3.5 (0.3-7.9) years, male to female ratio was 11:10. Fifteen patients had cervicothoracic tumors while 6 had apical thoracic tumors. All except 2 were primary tumors. They were stage M (n = 12), MS (n = 1), and L2 (n = 8). At pre-operative assessment, 19 patients had image-defined risk factor (IDRF), including dual compartmental involvement (n = 15), trachea/bronchus compression (n = 4), encasement of carotid (n = 5), subclavian (n = 11), and vertebral arteries (n = 6). Four underwent upfront surgery while 17 received pre-operative chemotherapy of 2-8 (mean 3.9) cycles. All patients accomplished gross total resection. None had MYCN amplification. The postoperative complications included Horner's syndrome (n = 21), Klumpke's palsy (n = 1), winged scapula (n = 1), phrenic nerve palsy (n = 1), and bronchomalacia (n = 2). Gross total resection of cervicothoracic and apical thoracic neuroblastoma can be accomplished by TAT with minimal morbidity.

P451Optimizing the EP lab workflow in atrial fibrillation ablation - The use of Z stitch for groin access closure

Abstract Introduction As catheter ablation became the standard therapy for atrial fibrillation (AF), the number of AF procedures has risen exponentially. Therefore, workflow optimization is crucial in order to meet the rising demands for EP interventions. Recently, instead of standard groin compression we have started using the "Z stitch" for introducers’ removal. This novel method does not necessitate protamine administration and often lengthy manual compression. Purpose We aim to demonstrate utilization of "Z stitch" for groin access closure in cryoballoon (CB) ablation and its impact on EP lab workflow. Methods We have analyzed all patients having undergone CB ablation utilizing the "Z stitch" (Z group) and the last 50 consecutive CB patients who received standard groin compression (non-Z group). Procedures were performed under conscious sedation. Both femoral veins were punctured and a single introducer was placed in each vein. A single transeptal puncture was preformed guided by intracardial ultrasound and a 28 mm cryoballoon was used. A single 180 seconds freeze strategy was employed. In the past, protamine was slowly administered after ablation and at least 15 minute manual groin compression was applied until no visual bleeding could be detected. Elastic bandage was placed around both groins. Later on, the "Z stitch" was used around both introducers without the need for protamine administration, manual compression and bandage placement (Picture). The stitches were removed next morning. Results A total of 100 consecutive patients (79% male, 61.2 ± 10.6 years old) were evaluated, 50 in both groups. There was no difference in the mean procedure duration ("skin to skin") between two groups. However, a total lab time was significantly longer in non-Z group. There was no differences in complication rates, which consisted solely of phrenic nerve palsy and groin complications. There was no AV fistula or pseudoaneurysms detected in our cohort (Table). Conclusion Utilization of Z stitches for introduces’ removal seems safe and effective way to achieve hemostasis after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious advert events. Manual compression is no longer required. Consequently, EP lab workflow is improved, since the total lab time utilization per patient is significantly shortened. Results non-Z group Z group p Procedure duration (min) 69.4 ± 20.4 73.4 ± 24.8 0.380 Lab time (min) 129.9 ± 35.3 109.1 ± 30.6 0.002 Complications (N) 5 (2 hematoma) 4 (2 hematoma) NS Abstract Figure. Z stich

Phrenic nerve injury in atrial fibrillation ablation using balloon catheters: Incidence, characteristics, and clinical recovery course.

Systematic data on phrenic nerve palsy (PNP) associated with contemporary balloon ablation techniques (cryoballoon [CBA] vs laser balloon [LBA]) are sparse. We aimed to investigate the incidence, characteristics, and clinical recovery course in patients with PNP who underwent CBA or LBA. A total of 2433 consecutive patients who underwent balloon-based pulmonary vein isolation (CBA: n = 1720 and LBA: n = 713) were retrospectively identified. PNP was classified into (a) transient (recovery before discharge) or (b) persistent (within 6 months, 6-12 months, and >12 months) according to clinical recovery course. In general, PNP occurred significantly more often in CBA 71/1720 (4.2%) than LBA 11/713 (1.5%) (P = .003). The rate of transient PNP was significantly higher in CBA (3.0%, n = 45) than LBA (0.1%, n = 1, P = .004). The rate of persistent PNP did not significantly differ between two groups (CBA: 1.2% vs LBA: 1.4%, P = .89). The rate of persistent PNP which recovered within 6 months was similar (CBA: 17.4% vs LBA 18.2%, P = 1.000). However, the rates of persistent PNP which recovered within 6 to 12 months (CBA: 2.9% vs LBA 27.3%, P = .0171) and more than 12 months (CBA: 7.3% vs LBA 45.5%, P = .0034) were significantly higher in LBA. PNP occurred more often in CBA than LBA, however, the majority of PNP in CBA was transient whereas the majority of PNP in LBA was persistent. Either balloon technology is not superior in terms of long-term PNP.

Cryoballoon pulmonary vein isolation as first line treatment for typical atrial flutter (CRAFT): study protocol for a randomised controlled trial

PurposeTreatment of typical atrial flutter (AFL) with cavo-tricuspid isthmus (CTI) ablation is associated with a high occurrence rate of new onset atrial fibrillation (AF) during follow-up. There are data to support the addition of pulmonary vein isolation (PVI) to CTI ablation in patients with both AF and AFL, but the role of cryoballoon PVI only, with no CTI ablation, in AFL patients with no prior documentation of AF has not been studied.MethodsCRAFT is an international, prospective, randomised, open with blinded assessment, multicentre superiority study comparing radiofrequency CTI ablation and cryoballoon PVI in patients with typical AFL. Participants with typical AFL are randomised in a 1:1 ratio to either treatment arm, with patients randomised to PVI not receiving CTI ablation. Post-procedural cardiac monitoring is performed using an implantable loop recorder. The primary endpoint is time to first recurrence of sustained symptomatic atrial arrhythmia. Key secondary endpoints include (1) total arrhythmia burden at 12 months, (2) time to first episode of AF lasting ≥ 2 min, (3) time to recurrence of AFL or AT and (4) procedural and fluoroscopy times. The primary safety endpoint is the composite of death, stroke/transient ischaemic attack, cardiac tamponade requiring drainage, atrio-oesophageal fistula, requirement for a permanent pacemaker, serious vascular complications requiring intervention or delaying discharge and persistent phrenic nerve palsy lasting > 24 h.ConclusionThis study compares the outcomes of 2 different approaches to typical AFL—the conventional ‘substrate’-based strategy of radiofrequency CTI ablation versus a novel ‘trigger’-based strategy of cryoballoon PVI.Trial registration(ClinicalTrials.gov ID: NCT03401099)

Safety and feasibility of electrical isolation of the superior vena cava in addition to pulmonary vein ablation for paroxysmal atrial fibrillation using the cryoballoon: lessons from a prospective study.

The purpose of this study was to evaluate the feasibility and safety of superior vena cava (SVC) isolation in addition to standard pulmonary vein isolation (PVI) using the second-generation cryoballoon (CB) in patients with paroxysmal atrial fibrillation. Thirty-seven consecutive patients that underwent CB ablation for paroxysmal atrial fibrillation (PAF) were prospectively enrolled in our study. After PVI the SVC was mapped for potentials. If the SVC exhibited electrical activity, isolation was achieved performing a single 180-s balloon application. Regarding SVC isolation, 180-s freeze in the SVC could be completed in 32 (86.4%) patients, and 5 patients had at least 120s of freezing application (13.5%). Real-time recording during SVC isolation was observed in 30 (81.0%) patients. The mean time to isolation was 36.9 ± 28.7s and the temperature at isolation was - 33 (- 15 to - 40) °C. No cases developed persistent phrenic nerve palsy (PNP) or any other complication. Superior vena cava isolation proved to be safe and feasible with the second generation cryoballoon in a prospective series of patients affected by PAF.

Safety and Efficacy of Cryoballoon Ablation for the Treatment of Atrial Fibrillation in Diabetic Patients.

Cryoballoon based catheter ablation (CB-CA) is an established therapy for treatment of symptomatic atrial fibrillation (AF). However, data about AF ablation using the CB in the diabetic population is sparse. The aim of this single center retrospective study is to evaluate the safety and efficacy of CB ablation in patients with diabetes mellitus (DM) as compared to patients without DM. Between July 2015 and December 2017, 397 consecutive patients underwent CB-CA for AF. Forty-eight consecutive patients with DM (DM group, study group) were compared with propensity score-matched patients without DM (n=48, control group). All patients underwent pulmonary vein isolation (PVI) using the second-generation CB (CB2). The mean age in the DM group was 66.9±9.5 years and 69.5±8.8 in the non-DM group (p=0.18). During a follow-up of 12.7±5.1 months, single procedure success rate for the DM and the non-DM group was 68.7% and 70.8%, respectively (p=0.82). The most common complication was transient phrenic nerve palsy (4 DM group vs. 0 non-DM group, p=0.04). No severe complication such as procedure related deaths, atrio-esophageal fistula or cerebrovascular embolic events occurred. Our data strengthen the value of CB2 based ablation for the treatment of AF as an effective and safe procedure in DM patients, with similar success rates when compared with a non-DM population.

Feasibility, safety, and acute efficacy of the fourth-generation cryoballoon for ablation of atrial fibrillation: Another step forward?

BackgroundThe second‐generation cryoballoon (CB2) is widely used for pulmonary vein (PV) isolation (PVI) in patients with paroxysmal atrial fibrillation (AF). Recently, the novel fourth‐generation CB (CB‐Advance PRO) was introduced, incorporating a shortened catheter tip.HypothesisThe aim of this study was to evaluate the feasibility and acute efficacy of PVI using the CB‐Advance PRO.MethodsA total of 200 consecutive patients were analyzed. Hundred patients who underwent PVI due to symptomatic, drug‐refractory AF were treated with the CB‐Advance PRO (group I) and were included into this multicenter analysis. A group of 100 patients were treated with the CB2 and acted as controls (group II).ResultsIn total, 739 of 739 PVs (100%) were successfully isolated. There was a nonsignificant trend in the incidence of online registration of PV signals between both groups (group I: 77.9% vs group II: 71.4%, P = .09). Median time to PVI (time to isolation [TTI]) and mean total freezing time were significantly shorter when using the CB‐Advance PRO (group I: 33 [23, 50] vs group II: 40 [26, 60] seconds and group I: 166 ± 29 vs group II: 183 ± 38 seconds, P < .01). In three of 100 (3%) patients of group I and one of 100 (1%) patients of group II, a transient phrenic nerve palsy occurred (P = .62).ConclusionThe use of the novel CB‐Advance PRO is feasible and associated with a significant reduction in mean TTI and mean total freezing time as compared to the CB2.

Cardiovascular surgery complication and the benefits of pulmonary rehabilitation in preventing COPD exacerbation

Introduction. Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide, and the burden of the disease is constantly increasing. Although COPD is primarily characterized by the presence of airflow obstruction, in many patients, it is associated with systemic manifestations that can result in impaired functional capacity, reduced quality of life, and increased mortality. Pulmonary rehabilitation (PR) consists of a multidisciplinary and comprehensive non-pharmacological intervention that is designed to improve health status in COPD patients, along with pharmacologic treatment. PR has also been shown to improve the diaphragmatic mobility in patients with different conditions that affect the diaphragm. The aim of the paper is to describe the clinical and functional features of a COPD patient with unilateral paralysis of the phrenic nerve and the role of PR as a major component of the case management. Material and method. This paper presents the case of a 66-year-old patient, diagnosed with COPD Gold stage III, which suffered a surgical intervention for an aorta aneurysm and later complicated with phrenic nerve injury and left diaphragmatic paralysis. This condition worsened the respiratory functional status and the patient needed a tailored treatment. Results and discussions. The treatment included besides inhaled dual long acting bronchodilator and corticoid therapy, pulmonary rehabilitation with complex methods, consisting in training of the respiratory musculature and techniques of bronchial drainage using devices with positive inspiratory and expiratory pressure, with good clinical and functional outcomes. A PR program should be included into a personalized management plan, along with pharmacological therapy. Conclusion. Although there is no standard treatment for COPD associated with unilateral paralysis of the phrenic nerve, it is important to diagnose these conditions promptly, and to recommend the adequate pharmacological treatment for controlling the symptoms along with a personalized complex respiratory rehabilitation program, in order to increase functional status and quality of life. Key words: respiratory rehabilitation, COPD, phrenic nerve paralysis

Phrenic nerve palsy during right-sided pulmonary veins cryoapplications: new insights from pulmonary vein anatomy addressed by computed tomography.

There is still sparse information regarding phrenic nerve palsy (PNP) during the cryoablation of both right-sided pulmonary vein (PV) and its anatomical predictors. Consecutive patients who had undergone pulmonary vein isolation (PVI) using CB-A and suffered PNP during both right-sided PVs were retrospectively included in our study. Two other groups were then selected among patients who experienced PNP during RIPV application only (group 2) and RSPV application only (group 3). The incidence of PNI during both right-sided PVs cryoapplications was 2.1%, (32 of 1542 patients). There were no significant clinical differences between the 3 groups. Time from basal temperature to -40°C significantly differed among the groups for both RIPV (p = 0.0026) and RSPV applications (p = 0.0382). Patients with PNP occurring during RSPV applications had significantly larger RSPV cross-sectional area compared to patients without PNP (p = 0.0116), while in patients with PNP during RIPV application, the angle of RIPV ostium on the transverse plane was significantly smaller compared to patients without PNP (p = 0.0035). The carina width was significantly smaller in patients with PNP occurring during both right-sided PVs cryoapplications compared to patients in which PNP occurred only during one right-sided PV application (p < 0.0001); a cutoff value of 8.5mm had a sensitivity of 87.3% and a specificity of 75.0%. PNP in both right-sided PVs applications is a complication that occurred in 2.1% of cases during CB-A. Pre-procedural evaluation of right PVs anatomy might be useful in evaluating the risk of PNP.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Comparative Study of Cryoballoon versus Radiofrequency for Pulmonary Vein Isolation when Combined with vein of Marshall Ethanol Infusion for Paroxysmal Atrial Fibrillation.

Ethanol infusion (EI) in the vein of Marshall (VOM) has multifactorial effects that could be synergistic to pulmonary vein isolation (PVI) in ablation of atrial fibrillation (AF). The efficacy of radiofrequency (RF) versus cryoablation when combined with a VOM-EI has never been investigated. The aim of this study is to evaluate outcome differences of AF ablation using RF versus cryoablation when combined with a VOM-EI. Consecutive patients (n=132) underwent catheter ablation of paroxysmal AF with either RF or cryoballoon (CB) for PVI combined with VOM-EI. Bi-directional conduction block at the mitral isthmus was attempted. The end-point was the freedom from any atrial arrhythmias documented after a blanking period of 90 days after the procedure. Kaplan-Meier estimates of the arrhythmia-free survival after 1 year were 63.8 (RF + VOM), and 82.7 % (CB + VOM), respectively. Comparison between CB + VOM versus RF + VOM reached a significance (p=0.0292). The periprocedural complication rate was comparable in both groups (5.0 % RF, 5.8 % CB; p=0.14) with a significant difference in the incidence of phrenic nerve palsy (0 % RF, 2.0 % CB; p<0.05). PVI with a CB had an increased freedom from AF recurrence compared to RF combined with VOM-EI. The present results suggest a potential additive effect of a VOM-EI to CB application.