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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Phrenic Nerve Injury After Atrial Fibrillation Catheter Ablation

Characterization and Outcome in a Multicenter Study

Frédéric Sacher, MD^_*,_*, Kristi H. Monahan, RN, Stuart P. Thomas, MD, Neil Davidson, MD, Pedro Adragao, MD^||, Prashanthan Sanders, MBBS, PhD^_*, Mélèze Hocini, MD^_*, Yoshihide Takahashi, MD^_*, Martin Rotter, MD^_*, Thomas Rostock, MD^_*, Li-Fern Hsu, MBBS^_*, Jacques Clémenty, MD^_*, Michel Haïssaguerre, MD^_*, David L. Ross, MD, Douglas L. Packer, MD and Pierre Jaïs, MD^_*

^_* Hôpital Cardiologique du Haut-Lévêque, Université Bordeaux II, Bordeaux-Pessac, France
Division of Cardiac Electrophysiology, Mayo Clinic and Foundation, Rochester, Minnesota
Department of Cardiology, Westmead Hospital, Sydney, Australia
Department of Cardiology, Wythenshawe Hospital, Manchester, United Kingdom
^|| Department of Cardiology, Hospital Santa Cruz, Carnaxide, Portugal.

Manuscript received October 26, 2005; revised manuscript received February 3, 2006, accepted February 7, 2006.

^_* Reprint requests and correspondence: Dr. Frédéric Sacher, Hôpital Cardiologique du Haut-Lévêque, 33604 Bordeaux-Pessac, France. (Email: frederic.sacher{at}chu-bordeaux.fr).

OBJECTIVES: The purpose of this study was to characterize the occurrence of phrenic nerve injury (PNI) and its outcome after radiofrequency (RF) ablation of atrial fibrillation (AF).

BACKGROUND: It is recognized that extra-myocardial damage may develop owing to penetration of ablative energy.

METHODS: Between 1997 and 2004, 3,755 consecutive patients underwent AF ablation at five centers. Among them, 18 patients (0.48%; 9 male, 54 ± 10 years) had PNI (16 right, 2 left). The procedure consisted of pulmonary vein (PV) isolation in 15 patients and anatomic circumferential ablation in 3 patients, with additional left atrial lesions (n = 11) and/or superior vena cava (SVC) disconnection (n = 4).

RESULTS: Right PNI occurred during ablation of right superior PV (n = 12) or SVC disconnection (n = 3). Left PNI occurred during ablation at the left atrial appendage. Immediate features were dyspnea, cough, hiccup, and/or sudden diaphragmatic elevation in 9, and in the remaining the diagnosis was made after ablation owing to dyspnea (n = 7) or on routine radiographic evaluation (n = 2). Four patients (22%) were asymptomatic. Complete recovery occurred in 12 patients (66%). Recovery occurred within 24 h in the two patients with left PNI and in one patient with right PNI occurring with SVC disconnection. In the other nine patients, right PNI recovery occurred after 4 ± 5 months (1 to 12 months) with respiratory rehabilitation. After a mean follow-up of 36 ± 33 months, six patients have persistent PNI (three with partial and three with no recovery).

CONCLUSIONS: In this multicenter experience, PNI was a rare complication (0.48%) of AF ablation. Ablation of the right superior PV, SVC, and left atrial appendage were associated with PNI. Complete (66%) or partial (17%) recovery was observed in the majority.

Abbreviations and Acronyms   AF = atrial fibrillation   LIPV = left inferior pulmonary vein   PN = phrenic nerve   PNI = phrenic nerve injury   PV = pulmonary vein   RF = radiofrequency   RSPV = right superior pulmonary vein   SVC = superior vena cava

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