Atrial tachycardias adjacent to the phrenic nerve: Recognition, potential problems, and solutions

TY - JOUR

T1 - Atrial tachycardias adjacent to the phrenic nerve: Recognition, potential problems, and solutions

AU - Lee, Joseph C.

AU - Steven, Daniel

AU - Roberts-Thomson, Kurt C.

AU - Raymond, Jean Marc

AU - Stevenson, William G.

AU - Tedrow, Usha B.

N1 - Funding Information: Dr. Steven has received a research grant from Biosense-Webster; Dr. Roberts-Thomson has received a Postgraduate Research Scholarship from the National Health and Medical Research Council of Australia (NHMRC grant ID 489417) and the Astra-Zeneca Fellowship in Medical Research from the Royal Australian College of Physicians; Dr. Stevenson has received speaking honoraria <$10,000 from Medtronic, St. Jude, Boston Scientific, Biosense-Webster, and consultant fees <$10,000 from Biosense-Webster. Dr. Tedrow has received speaking honoraria <$10,000 from Medtronic, Boston Scientific, St. Jude, and research grants <$20,000 from Biosense-Webster and Boston Scientific.

PY - 2009/8

Y1 - 2009/8

N2 - Background: Ablation of atrial tachycardias (AT) arising from the crista terminalis region (CT) can be complicated by phrenic nerve (PN) injury. Objective: This study sought to describe epicardial protection techniques to prevent PN injury from endocardial ablation of AT. Methods: Ablation was attempted in 4 patients with focal AT arising from the CT in whom conventional endocardial ablation was limited by PN proximity identified by capture during pacing. Results: Four women ages 20, 28, 30, and 31 years with structurally normal hearts presented with symptomatic ATs failing medical therapy. In the first patient, endocardial cryoablation was performed during superior vena cava (SVC) PN pacing. After acute success, AT recurred. Open surgical ablation was then performed, but AT was noninducible under anesthesia, and an anatomic ablation was performed. AT was abolished, but sinus node dysfunction required pacemaker implantation. In the subsequent 3 patients with AT adjacent to the right PN, protection of the PN was attempted by inserting a peripheral angioplasty balloon (2 patients) or steerable ablation catheter and sheath into the epicardial space between the PN and atrium. Endocardial radiofrequency ablation was successful in all 3 patients without PN injury. Conclusion: Epicardial protection of the PN allowing for safe endocardial ablation of CT ATs is a feasible method of managing these challenging cases and seems to be preferable to surgery.

AB - Background: Ablation of atrial tachycardias (AT) arising from the crista terminalis region (CT) can be complicated by phrenic nerve (PN) injury. Objective: This study sought to describe epicardial protection techniques to prevent PN injury from endocardial ablation of AT. Methods: Ablation was attempted in 4 patients with focal AT arising from the CT in whom conventional endocardial ablation was limited by PN proximity identified by capture during pacing. Results: Four women ages 20, 28, 30, and 31 years with structurally normal hearts presented with symptomatic ATs failing medical therapy. In the first patient, endocardial cryoablation was performed during superior vena cava (SVC) PN pacing. After acute success, AT recurred. Open surgical ablation was then performed, but AT was noninducible under anesthesia, and an anatomic ablation was performed. AT was abolished, but sinus node dysfunction required pacemaker implantation. In the subsequent 3 patients with AT adjacent to the right PN, protection of the PN was attempted by inserting a peripheral angioplasty balloon (2 patients) or steerable ablation catheter and sheath into the epicardial space between the PN and atrium. Endocardial radiofrequency ablation was successful in all 3 patients without PN injury. Conclusion: Epicardial protection of the PN allowing for safe endocardial ablation of CT ATs is a feasible method of managing these challenging cases and seems to be preferable to surgery.

KW - Ablation complications

KW - Atrial tachycardia

KW - Epicardial ablation

KW - Epicardial balloon placement

KW - Phrenic nerve injury

UR - http://www.scopus.com/inward/record.url?scp=67650716280&partnerID=8YFLogxK

U2 - 10.1016/j.hrthm.2009.03.056

DO - 10.1016/j.hrthm.2009.03.056

M3 - SCORING: Journal article

C2 - 19632631

AN - SCOPUS:67650716280

VL - 6

SP - 1186

EP - 1191

JO - HEART RHYTHM

JF - HEART RHYTHM

SN - 1547-5271

IS - 8

ER -