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(BQ) Part 2 book "The practice of catheter cryoablation for cardiac arrhythmias" presents the following contents: Prevention of phrenic nerve palsy during cryoballoon ablation for atrial fibrillation, linear isthmus ablation for atrial flutter - Catheter cryoablation versus radiofrequency catheter ablation, catheter cryoablation for the treatment of accessory pathways,. | CHAPTER 6 Prevention of Phrenic Nerve Palsy during Cryoballoon Ablation for Atrial Fibrillation Marcin Kowalski Staten Island University Hospital Staten Island NY USA Introduction Injury to the right phrenic nerve is the most common complication associated with pulmonary vein PV isolation when using cryoenergy. The injury may range from transient impairment of diaphragmatic function to permanent phrenic nerve palsy PNP . On account of the anatomical course of the phrenic nerve injury to the nerve occurs more frequently during ablation of the right superior pulmonary vein RSPV than during ablation of the right inferior pulmonary vein RIPV .1 The incidence of phrenic nerve injury PNI during cryoballoon ablation has been reported to be between 2 and 11 1-5 and a meta-analysis of 23 articles reported PNI in 6.38 of the cases.6 In the majority of the cases phrenic nerve function recovered within one year. In the Sustained Treatment of Paroxysmal Atrial Fibrillation STOP AF trial a randomized trial comparing cryoballoon ablation with antiarrhythmic medications there were 29 cases of PNI of which 4 persisted after one year.5 In the US Continued Access Protocol CAP-AF registry 4 out of 71 cases 5.6 had PNI with complete resolution in 3 patients.7 In comparison to the cryoballoon technique during PV isolation using radiofrequency energy PNI is a rare complication 0.48 and is frequently associated with ablation of the right PV orifice the superior vena cava SVC and the roof of the left atrial appendage.8-10 Anatomy The phrenic nerve originates from the third fourth and fifth cervical nerves and provides the only motor supply to the diaphragm as well as sensation to the central tendon mediastinal pleura and pericardium. The nerve descends almost vertically along the right brachiocephalic vein and continues along the right anterolateral surface of the SVC Figure 6.1 . The phrenic nerve is separated from the SVC by only the pericardium at the anterolateral junction between the
