Mechanisms of phrenic nerve injury during radiofrequency ablation at the pulmonary vein orifice

T. Jared Bunch, G. Keith Bruce, Srijoy Mahapatra, Susan B. Johnson, Dylan V. Miller, Alvaro V. Sarabanda, Mark A. Milton, Douglas L Packer

Research output: Contribution to journalArticle

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Abstract

Mechanisms of Phrenic Nerve Injury. Background: The phrenic nerve can be injured with radiofrequency energy delivery. Nevertheless, the mechanisms of injury are unknown. This study was undertaken to examine phrenic nerve tissue temperatures during ablation at the pulmonary vein (PV) orifice, assess the temperature dependence of injury, and to delineate the possible mechanisms of untoward nerve effects. Methods: Ten dogs underwent ablation at the right superior PV (RSPV) orifice. Phrenic nerve temperatures were assessed with implanted thermocouples overlying the endocardial ablation site. Using an 8-mm ablation catheter tip, energy was titrated to 50°C and incremented by 5°C for 120 seconds. Results: Phrenic nerve capture was achieved in nine (90%) dogs after thermocouple implantation. A RSPV orifice tissue temperature >60°C occurred in 32 (84%) of energy deliveries with a power of 34 ± 22 W. In three (33%) dogs, this resulted in nerve dysfunction (maximum nerve temperature: 41°C, 41°C, and 91°C) with histology consistent with acute thermal injury. In four additional dogs, 17 energy deliveries were made directly to the phrenic nerve using a novel in situ model. In 5 (29%) energy deliveries, nerve function was impacted immediately by the generated current, with resolution simultaneous with discontinuing radiofrequency. Transient phrenic nerve injury occurred in all dogs at a temperature of 47 ± 3°C (range: 43-53°C) after 38 ± 32 seconds (range: 20-120 seconds). After termination of the energy delivery, nerve function returned in 15(88%) during 30 seconds of postablation pacing. In two (12%) ablation attempts, nerve recovery was delayed (>3 minutes). Permanent injury occurred in all dogs after 92 ± 83 seconds (range: 20-280 seconds) of additional energy delivery at a temperature of 51 ± 6°C (range: 45-65°C). Conclusion: Phrenic nerve injury can be more common than anticipated with RF ablation at the RSPV orifice. Relatively low tissue temperatures can injure the nerve. Immediate nerve effects suggest a second mechanism of nerve dysfunction related to electrical current. Transient nerve effects occur prior to permanent damage, providing an opportunity to discontinue energy delivery before permanent injury.

Original languageEnglish (US)
Pages (from-to)1318-1325
Number of pages8
JournalJournal of Cardiovascular Electrophysiology
Volume16
Issue number12
DOIs
StatePublished - Dec 2005

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Phrenic Nerve
Pulmonary Veins
Temperature
Wounds and Injuries
Dogs
Nerve Tissue
Catheter Ablation
Histology
Hot Temperature

Keywords

  • Ablation
  • Arrhythmia
  • Atrium
  • Fibrillation
  • Myocardium
  • Nervous system

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

Cite this

Mechanisms of phrenic nerve injury during radiofrequency ablation at the pulmonary vein orifice. / Bunch, T. Jared; Bruce, G. Keith; Mahapatra, Srijoy; Johnson, Susan B.; Miller, Dylan V.; Sarabanda, Alvaro V.; Milton, Mark A.; Packer, Douglas L.

In: Journal of Cardiovascular Electrophysiology, Vol. 16, No. 12, 12.2005, p. 1318-1325.

Research output: Contribution to journalArticle

Bunch, T. Jared ; Bruce, G. Keith ; Mahapatra, Srijoy ; Johnson, Susan B. ; Miller, Dylan V. ; Sarabanda, Alvaro V. ; Milton, Mark A. ; Packer, Douglas L. / Mechanisms of phrenic nerve injury during radiofrequency ablation at the pulmonary vein orifice. In: Journal of Cardiovascular Electrophysiology. 2005 ; Vol. 16, No. 12. pp. 1318-1325.
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abstract = "Mechanisms of Phrenic Nerve Injury. Background: The phrenic nerve can be injured with radiofrequency energy delivery. Nevertheless, the mechanisms of injury are unknown. This study was undertaken to examine phrenic nerve tissue temperatures during ablation at the pulmonary vein (PV) orifice, assess the temperature dependence of injury, and to delineate the possible mechanisms of untoward nerve effects. Methods: Ten dogs underwent ablation at the right superior PV (RSPV) orifice. Phrenic nerve temperatures were assessed with implanted thermocouples overlying the endocardial ablation site. Using an 8-mm ablation catheter tip, energy was titrated to 50°C and incremented by 5°C for 120 seconds. Results: Phrenic nerve capture was achieved in nine (90{\%}) dogs after thermocouple implantation. A RSPV orifice tissue temperature >60°C occurred in 32 (84{\%}) of energy deliveries with a power of 34 ± 22 W. In three (33{\%}) dogs, this resulted in nerve dysfunction (maximum nerve temperature: 41°C, 41°C, and 91°C) with histology consistent with acute thermal injury. In four additional dogs, 17 energy deliveries were made directly to the phrenic nerve using a novel in situ model. In 5 (29{\%}) energy deliveries, nerve function was impacted immediately by the generated current, with resolution simultaneous with discontinuing radiofrequency. Transient phrenic nerve injury occurred in all dogs at a temperature of 47 ± 3°C (range: 43-53°C) after 38 ± 32 seconds (range: 20-120 seconds). After termination of the energy delivery, nerve function returned in 15(88{\%}) during 30 seconds of postablation pacing. In two (12{\%}) ablation attempts, nerve recovery was delayed (>3 minutes). Permanent injury occurred in all dogs after 92 ± 83 seconds (range: 20-280 seconds) of additional energy delivery at a temperature of 51 ± 6°C (range: 45-65°C). Conclusion: Phrenic nerve injury can be more common than anticipated with RF ablation at the RSPV orifice. Relatively low tissue temperatures can injure the nerve. Immediate nerve effects suggest a second mechanism of nerve dysfunction related to electrical current. Transient nerve effects occur prior to permanent damage, providing an opportunity to discontinue energy delivery before permanent injury.",
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AU - Bunch, T. Jared

AU - Bruce, G. Keith

AU - Mahapatra, Srijoy

AU - Johnson, Susan B.

AU - Miller, Dylan V.

AU - Sarabanda, Alvaro V.

AU - Milton, Mark A.

AU - Packer, Douglas L

PY - 2005/12

Y1 - 2005/12

N2 - Mechanisms of Phrenic Nerve Injury. Background: The phrenic nerve can be injured with radiofrequency energy delivery. Nevertheless, the mechanisms of injury are unknown. This study was undertaken to examine phrenic nerve tissue temperatures during ablation at the pulmonary vein (PV) orifice, assess the temperature dependence of injury, and to delineate the possible mechanisms of untoward nerve effects. Methods: Ten dogs underwent ablation at the right superior PV (RSPV) orifice. Phrenic nerve temperatures were assessed with implanted thermocouples overlying the endocardial ablation site. Using an 8-mm ablation catheter tip, energy was titrated to 50°C and incremented by 5°C for 120 seconds. Results: Phrenic nerve capture was achieved in nine (90%) dogs after thermocouple implantation. A RSPV orifice tissue temperature >60°C occurred in 32 (84%) of energy deliveries with a power of 34 ± 22 W. In three (33%) dogs, this resulted in nerve dysfunction (maximum nerve temperature: 41°C, 41°C, and 91°C) with histology consistent with acute thermal injury. In four additional dogs, 17 energy deliveries were made directly to the phrenic nerve using a novel in situ model. In 5 (29%) energy deliveries, nerve function was impacted immediately by the generated current, with resolution simultaneous with discontinuing radiofrequency. Transient phrenic nerve injury occurred in all dogs at a temperature of 47 ± 3°C (range: 43-53°C) after 38 ± 32 seconds (range: 20-120 seconds). After termination of the energy delivery, nerve function returned in 15(88%) during 30 seconds of postablation pacing. In two (12%) ablation attempts, nerve recovery was delayed (>3 minutes). Permanent injury occurred in all dogs after 92 ± 83 seconds (range: 20-280 seconds) of additional energy delivery at a temperature of 51 ± 6°C (range: 45-65°C). Conclusion: Phrenic nerve injury can be more common than anticipated with RF ablation at the RSPV orifice. Relatively low tissue temperatures can injure the nerve. Immediate nerve effects suggest a second mechanism of nerve dysfunction related to electrical current. Transient nerve effects occur prior to permanent damage, providing an opportunity to discontinue energy delivery before permanent injury.

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KW - Ablation

KW - Arrhythmia

KW - Atrium

KW - Fibrillation

KW - Myocardium

KW - Nervous system

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