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

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

Research output: Contribution to journalArticle

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Abstract

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.

Original languageEnglish
Pages (from-to)957-961
Number of pages5
JournalHeart Rhythm
Volume6
Issue number7
DOIs
Publication statusPublished - Jul 2009

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Phrenic Nerve
Wounds and Injuries
Air
Catheter Ablation
Pericardium
Blood Pressure
Cardiac Arrhythmias
Economic Inflation

Keywords

  • Arrhythmias
  • Catheter ablation
  • Complications
  • Phrenic nerve injury

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

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.

In: Heart Rhythm, Vol. 6, No. 7, 07.2009, p. 957-961.

Research output: Contribution to journalArticle

Di Biase, L, Burkhardt, JD, Pelargonio, G, Dello Russo, A, Casella, M, Santarelli, P, Horton, R, Sanchez, J, Gallinghouse, JG, Al-Ahmad, A, Wang, P, Cummings, JE, Schweikert, RA & Natale, A 2009, 'Prevention of phrenic nerve injury during epicardial ablation: Comparison of methods for separating the phrenic nerve from the epicardial surface', Heart Rhythm, vol. 6, no. 7, pp. 957-961. https://doi.org/10.1016/j.hrthm.2009.03.022
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. / Prevention of phrenic nerve injury during epicardial ablation : Comparison of methods for separating the phrenic nerve from the epicardial surface. In: Heart Rhythm. 2009 ; Vol. 6, No. 7. pp. 957-961.
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abstract = "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.",
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T1 - Prevention of phrenic nerve injury during epicardial ablation

T2 - Comparison of methods for separating the phrenic nerve from the epicardial surface

AU - Di Biase, Luigi

AU - Burkhardt, J. David

AU - Pelargonio, Gemma

AU - Dello Russo, Antonio

AU - Casella, Michela

AU - Santarelli, Pietro

AU - Horton, Rodney

AU - Sanchez, Javier

AU - Gallinghouse, Joseph G.

AU - Al-Ahmad, Amin

AU - Wang, Paul

AU - Cummings, Jennifer E.

AU - Schweikert, Robert A.

AU - Natale, Andrea

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N2 - 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.

AB - 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.

KW - Arrhythmias

KW - Catheter ablation

KW - Complications

KW - Phrenic nerve injury

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