Phrenic Nerve Injury (PNI) is a well known, although uncommon, complication of pulmonary vein isolation (PVI) using radiofrequency energy. Currently, there is no consensus about how to avoid or minimize this injury. The purpose of this study was determine how often the phrenic nerve, as identified using high output pacing, lies along the ablation trajectory of a wide area circumferential lesion set. We also sought to determine if PVI can be achieved without phrenic nerve injury by modifying the ablation lesion set so as to avoid those areas where phrenic nerve capture (PNC) is observed. and ResultsWe prospectively enrolled 100 consecutive patients (age 61.7 ± 9.2 year-old, 75 men) who underwent RF PVI using wide area circumferential ablation approach. High output (20 mA at 2 ms) endocardial pacing protocol was performed around the right pulmonary veins and the carina where a usual ablation lesion set would be made. 30% of patients had PNC and required modification of ablation lines. In the group of patients with PNC, the carina was the most common site of capture (85%) followed by anterior right superior pulmonary vein (RSPV) (70%) and anterior right inferior pulmonary vein (RIPV) (30%). 25% of PNC group had capture in all three (RSPV, RIPV and carina) regions. There was no difference in the clinical characteristics between the groups with and without PNC. RF PVI caused no PNI in either group. High output pacing around the right pulmonary veins and the carina reveals that the phrenic nerve lies along a wide area circumferential ablation trajectory in 30% of patients. Modification of ablation lines to avoid these sites may prevent phrenic nerve injury during RF PVI.
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