Prevention of phrenic nerve injury during epicardial ablation: Comparison of methods for separating the phrenic nerve from the epicardial surface

Di Biase, Luigi; Burkhardt, J. David; Pelargonio, Gemma; Dello Russo, Antonio; Casella, Michela; Santarelli, Pietro; Horton, Rodney; Sanchez, Javier; Gallinghouse, Joseph G.; Al-Ahmad, Amin; Wang, Paul; Cummings, Jennifer E.; Schweikert, Robert A.; Natale, Andrea

doi:10.1016/j.hrthm.2009.03.022

« Previous Next »Heart Rhythm
Volume 6, Issue 7 , Pages 957-961, July 2009

Prevention of phrenic nerve injury during epicardial ablation: Comparison of methods for separating the phrenic nerve from the epicardial surface

Luigi Di Biase, MD
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
- Department of Cardiology, University of Foggia, Foggia, Italy
J. David Burkhardt, MD
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
Gemma Pelargonio, MD
- Catholic University, Rome, Italy
Antonio Dello Russo, MD
- Catholic University, Rome, Italy
Michela Casella, MD
- Catholic University, Rome, Italy
Pietro Santarelli, MD
- Catholic University, Rome, Italy
Rodney Horton, MD
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
Javier Sanchez, MD
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
Joseph G. Gallinghouse, MD
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
Amin Al-Ahmad, MD
- Stanford University, Palo Alto, California
Paul Wang, MD
- Stanford University, Palo Alto, California
Jennifer E. Cummings, MD
- Akron General Hospital, Akron, Ohio
Robert A. Schweikert, MD
- Akron General Hospital, Akron, Ohio
Andrea Natale, MD, FHRS
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
- Stanford University, Palo Alto, California
- Akron General Hospital, Akron, Ohio
- Address reprint requests and correspondence: Dr. Andrea Natale, 1015 East 32^nd Street, Austin, TX 78705

Received 26 January 2009; accepted 12 March 2009. published online 20 March 2009.

Background

The proximity of the phrenic nerve (PN) to cardiac tissue relevant to arrhythmias may increase the risk of PN injury. Strategies for preventing PN injury in the pericardial space are limited.

Objective

The purpose of this study was to compare methods for separating the PN from the epicardial surface in order to prevent PN injury.

Methods

Eight patients referred for epicardial ablation of arrhythmias were enrolled in the study. All patients required ablation near the PN. Endocardial and epicardial access was obtained in all patients. A three-dimensional mapping system was used to guide mapping and ablation. All patients underwent epicardial catheter ablation. Pacing via the ablation catheter identified the location of the PN. In order to prevent PN injury, four new strategies were tested in each patient. We sought to increase the distance between the epicardium and the PN by (1) placing a large-diameter balloon between the nerve and the myocardium, (2) introducing saline in steps of 20 ml until PN capture was lost or blood pressure dropped below 60 mmHg, (3) introducing air until PN capture was lost or blood pressure dropped below 60 mmHg, or (4) introducing a combination of saline and air until PN capture was lost or blood pressure dropped below 60 mmHg.

Results

At each step, epicardial pacing was performed to assess for PN stimulation. The combination of air and saline resulted in the greatest decrease of PN stimulation. Saline only failed in all cases. Air only and balloon placement were infrequently successful.

Conclusion

Controlled and progressive inflation of air and saline together with careful monitoring of hemodynamic parameters appears to be the best strategy for preventing PN injury during epicardial ablation. Placement of a large balloon in the appropriate location can be difficult.

Keywords: Catheter ablation, Arrhythmias, Complications, Phrenic nerve injury