Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
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Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
CHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 Island. NY. USAIntroductionInjury to the right phrenic nerve is the most common complication associated with pulmonary vein IPX’) isoliltion when using cryoenergy. The injury may range from transient impairment of diaphragmatic function to permanent phrenic nerve palsy (PNP). On account of the anat Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2omical course of the phrenic nerve, injury to the nerve occurs more frequently during ablation of the right superior pulmonary vein (RSPV) than duringEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
ablation of the right inferior pulmonary vein IRII’VI.1The Incidence of phrenic nerve injury (PNI) during cryoballoon ablation has been reported to bCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2ecovered within one year. In the Sustained Treatment of Paroxysmal Atrial Fibrillation (STOP API triill. a randomized trial comparing cryobidloon ablation with antiarrhythmlc medications, there were 29 cases of PNI. of which 4 persisted after one year? In the US Continued Access Protocol (CAP-AF) re Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2gistry. 4 out of 71 cases (5.6%) had PNI, with complete resolution in 3 patients.7 In comparison to thecryoballoon technique, during PV isolation usinEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
g radiofrequency energy. PN1 is a rare complication (0.48%) and is frequently associated with ablation of the right PV orifice, the superior vena cavaCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 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 septira Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2ted from the SVC by only the pericardium at the anterolateral junction between the SVC and the right atrium.11 The close proximity of the nerve to theEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
SVC Widl in this location can facilitate capture of the nerve while pacing from the lateral wall of the SVC. Descending the anterolateral Willi of thCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2hingThe Practice !>/ Catheter CtyoaNatlon/or CanỉiíiK’ Arrhythmias. First Edition. Edited by Ngal-Yln Chilli.S' 2014 John Wiley & Sons. Ud. Published 2014 by John Wiley & Sons. Ud.6768 Catheter Cryoablation for Cardiac ArrhythmiasFigure 6.1. (a) Specimen shows the course of the phrenic nerve and the Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 close anatomic relationship to other structures. RB: right bronchus: Rl: right inferior RM: right middle: RPA: right pulmonary artery: RS: right supeEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
rior pulmonary veins: SCV: superior vena cava. (Source: Ho SY. Cabrera JA. Sanchez-Quintana I). 2012". Reproduced with permission from Wolters Kluwer CHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2adherent to the fibrous pericardium (thin red-green line). The broken lines Indicate the pulmonary venous orifices. Note the myocardial sleeve (red) on the outer side of the RSPV. ICV: inferior vena cava: PA: pulmonary artery: R1PV: right inferior pulmonary vein: RSPV: right superior pulmonary vein: Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 SCV: superior caval vein. (Masson’s trichromc slain.) (Source: Sanchez-Quintana I). Cabrera JA. Cllment V. Farre J. Welgleln A. Ho SY. 2O()5u. ReprodEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
uced with permission from John Wiley and Sons Ltd).the diaphragm. Histologic examination of the transverse sections revealed that the phrenic nerve isCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 RSPV renders it more vulnerable to injury during cryoballoon ablation of the RSPV then during ablation of the RII’V.Mechanisms of phrenic nerve injuryThe mechanisms of PNI during cryoballoon application are presumably multifactorial liable 6.11. The mechanisms of cellular damage that are secondary' Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 to the cryoenergy application include ice crystal formation in the extracellular space, resulting in a hyperosmotic milieu in extravascular spaces thEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
at draws water from the cell, causing intracellular desiccation. As the temperature decreases, the extracellular crystals increase in number and causeCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 A delayed direct cell injury may result from apoptosis, inflammation, coagulation necrosis ofTable 6.1. Mechanisms of phrenic nerve injuryProximity of the phrenic nerve (PN) to the pulmonary win (PV)Distortion of the PV geometry by the balloon inflationExcessive temperatureDuration of the freezeRep Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2etitive freeze-thaw cycleVasoconstriction, thrombosis, and ischemia caused by hypothermiaPrevious injury to the nervethe cell, and replacement fibrosiEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
s. ”,H Vascular responses to cold temperature include vasoconstriction causing ischemia and circulatory stasis, which has also been shown to play an iCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2f damage to the nerve. The tissue is cooled with outward expansion in a concentric fashion from the cryobidloon surface touching the cardiac tissue.K The closer the phrenic nerve is to the atrial tissuePhrenic Nerve Palsy Prevention 69adjoining the cryoballoon surface, the colder the temperatures ar Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2e near the nerve, making nerve damage more likely. Okumura el al. showed in 10 dogs that balloon inllation al the PV orilice alters the geometry of thEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
e native RSPV endocardial surface and reduces the distance between the balloon and the phrenic nerve.1'* rhe inflated balloon surface extended outsideCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2d I he RSPV orifice moved the anatomic position of the phrenic nerve on average by 4.3 + 2.9 min in (he anterior to lateral directions, rhe degree of anatomic distortion is amplified when the balloon is pushed slightly into the PV to minimize leaks.rhe temperature achieved during a freeze and the du Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2ration of cryoapplication can make a significant difference in the incidence of PNI and the recovery of the nerve function. Colder temperatures achievEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
ed during the freeze expand the cold front further into the tissue, creating a deeper lesion and increasing the chance of reaching detrimental temperaCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 isotherm will be located 3 mm deep. If the temperature, however, decreases to -90 °C. the isotherm will be roughly 1.4 cm deep.1. Exposure to freezing temperatures can induce responses in the tissues that vary from inflammation during minor cold injury to tissue destruction during greater cold inju Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2ry.14 Rased on previous research, peripheral nerves lose function when exposed to a temperature of 0 to -5 °C. The function returns when the temperatuEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
re rises if the sheath is intact.15•” last freezing of tissue occurs only very close to the balloon. Most of the frozen volume of tissue experiences sCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2. Therefore. it is imperative to position I he balloon as antral as possible. As the duration of the cryoab-lation is extended, the size of the lesion continues to expand and the affected area becomes larger. Animals that were randomized to longer application duration demonstrated a higher degree of Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2 cell destruction and fibrotic content.'1 lesion size continues to expand during the cryoablation application. which can last up to 2-3 minutes.1' BeaEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
zleyand colleagues showed that the length of the nerve regeneration period or the duration of the nerve palsy is predictable based on the distance betCHAPTER 6Prevention of Phrenie Nerve Palsy duringCryoballoon Ablation for Atrial FibrillationMarcin KowalskiStaten Island University Hospital. Staten Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2nergy is stopped early enough to prevent prolonged exposure of the phrenic nerve to lethal temperatures, the injury to the nerve can be reversed.Other mechanisms of P\’I include vasoconstriction and decreased bkxxl How induced by hypot hermia. The decrease in bkxxl supply to the nerve can intensify Ebook The practice of catheter cryoablation for cardiac arrhythmias: Part 2the injury.222’ Also, a repetitive freezethaw cycle can be more destructive to the tissue, as the conduction of the cold front through the tissue is fEbook The practice of catheter cryoablation for cardiac arrhythmias: Part 2
aster with repeated freezing and larger crystals may result from the fusion of previously formed crystals.” -h when tissue cooling is faster and the vGọi ngay
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