Phrenic Nerve Injury During Cryoballoon-Based Pulmonary Vein Isolation: Results of the Worldwide YETI Registry

Background: Cryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce. Methods: The YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible. Results: A total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 17 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was −49±8 °C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months. Conclusions: The incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03645577.

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Anatomic predictors of phrenic nerve injury in the setting of pulmonary vein isolation using the 28-mm second-generation cryoballoon

Heart Rhythm ◽

10.1016/j.hrthm.2015.10.017 ◽

2016 ◽

Vol 13 (2) ◽

pp. 342-351 ◽

Cited By ~ 22

Author(s):

Erwin Ströker ◽

Carlo de Asmundis ◽

Yukio Saitoh ◽

Vedran Velagić ◽

Giacomo Mugnai ◽

...

Keyword(s):

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Phrenic Nerve ◽

Second Generation ◽

Phrenic Nerve Injury

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Phrenic Nerve Injury: An Underrecognized and Potentially Preventable Complication of Pulmonary Vein Isolation Using a Wide-Area Circumferential Ablation Approach

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.12210 ◽

2013 ◽

Vol 24 (10) ◽

pp. 1086-1091 ◽

Cited By ~ 6

Author(s):

Sang Yong Ji ◽

Jane Dewire ◽

Bernadette Barcelon ◽

Binu Philips ◽

John Catanzaro ◽

...

Keyword(s):

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Phrenic Nerve ◽

Wide Area ◽

Phrenic Nerve Injury ◽

Preventable Complication

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Left‐sided phrenic nerve injury during redo pulmonary vein isolation long after a previous contralateral self‐limiting phrenic nerve palsy

Clinical Case Reports ◽

10.1002/ccr3.2199 ◽

2019 ◽

Vol 7 (7) ◽

pp. 1391-1394

Author(s):

Zsuzsanna Kis ◽

Anna Maria Elisabeth Noten ◽

Sip Wijchers ◽

Rohit Bhagwandien ◽

Tamas Szili‐Torok

Keyword(s):

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Phrenic Nerve ◽

Nerve Palsy ◽

Phrenic Nerve Palsy ◽

Phrenic Nerve Injury

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Use of Intracardiac Echocardiography for Early Detection of Phrenic Nerve Injury During Cryoballoon Pulmonary Vein Isolation

Journal of Cardiovascular Electrophysiology ◽

10.1111/j.1540-8167.2012.02302.x ◽

2012 ◽

Vol 23 (8) ◽

pp. 874-876 ◽

Cited By ~ 23

Author(s):

MAYUR LAKHANI ◽

FAISAL SAIFUL ◽

SOAD BEKHEIT ◽

MARCIN KOWALSKI

Keyword(s):

Early Detection ◽

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Phrenic Nerve ◽

Intracardiac Echocardiography ◽

Phrenic Nerve Injury

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First report of phrenic nerve injury during pulmonary vein isolation using the Ablation Frontiers pulmonary vein ablation catheter

Journal of Interventional Cardiac Electrophysiology ◽

10.1007/s10840-010-9517-1 ◽

2010 ◽

Vol 29 (3) ◽

pp. 187-190 ◽

Cited By ~ 13

Author(s):

Syed Y. Ahsan ◽

Andrew S. Flett ◽

Pier D. Lambiase ◽

Oliver R. Segal

Keyword(s):

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Phrenic Nerve ◽

Ablation Catheter ◽

First Report ◽

Phrenic Nerve Injury ◽

Pulmonary Vein Ablation ◽

Pulmonary Vein Ablation Catheter

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Predictors of Phrenic Nerve Injury During Pulmonary Vein Isolation for Curing Atrial Fibrillation With Balloon-Based Visually Guided Laser Ablation

Circulation Journal ◽

10.1253/circj.cj-20-0953 ◽

2021 ◽

Vol 85 (3) ◽

pp. 275-282

Author(s):

Shinichi Tachibana ◽

Kaoru Okishige ◽

Koji Sudo ◽

Takatoshi Shigeta ◽

Yuichiro Sagawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Laser Ablation ◽

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Phrenic Nerve ◽

Visually Guided ◽

Phrenic Nerve Injury

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Pulmonary vein measurements on pre-procedural CT/MR imaging can predict difficult pulmonary vein isolation and phrenic nerve injury during cryoballoon ablation for paroxysmal atrial fibrillation

International Journal of Cardiology ◽

10.1016/j.ijcard.2015.05.089 ◽

2015 ◽

Vol 195 ◽

pp. 253-258 ◽

Cited By ~ 16

Author(s):

Richard Ang ◽

Ross J. Hunter ◽

Victoria Baker ◽

Laura Richmond ◽

Mehul Dhinoja ◽

...

Keyword(s):

Atrial Fibrillation ◽

Mr Imaging ◽

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Phrenic Nerve ◽

Cryoballoon Ablation ◽

Phrenic Nerve Injury

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6121Phrenic nerve injury during pulmonary vein isolation using the second-generation cryoballoon: characteristics and follow-up - The YETI registry

European Heart Journal ◽

10.1093/eurheartj/ehz746.0147 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

C H Heeger ◽

A Pott ◽

C Sohns ◽

A Rillig ◽

M Kuniss ◽

...

Keyword(s):

Nerve Injury ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Second Generation ◽

Pulmonary Veins ◽

Complication Rates ◽

Effective Treatment Option ◽

The Mean ◽

The Right

Abstract Background Second-generation cryoballoon (CB2) based pulmonary vein isolation (PVI) has emerged as a safe and effective treatment option for symptomatic atrial fibrillation (AF). Although published complication rates of CB2 based-PVI are relatively low and several safety algorithms have been implemented in the protocols the most frequent complication is right-sided phrenic nerve injury (PNI). The reported incidence of PNI varies from 2–5% of patients. However data on PNI characteristics as well as follow-up is sparse. Purpose We aimed to evaluate the incidence, characteristics and outcome of PNI during after CB2 based-PVI in a large patients population. Methods and results From July 2012 to November 2018 a total of 13693 patients received CB2 or CB3 (third-generation) based-PVI in 23 EP centers (Germany: 12, China: 1, Turkey: 3, Japan: 3, USA: 1, Austria: 1, Poland: 1, Swizerland: 1). A total of 596 (4.4%) of patients experienced PNI during treatment of the right superior (84%) right inferior (15%) right middle (0.3%) (and left superior (0.3%) pulmonary veins. The mean time to PNI was 127±51 seconds and the mean temperature at the time of PNI was −49±7 °C. The target PV was isolated at time of PNI in 84% of cases. The applications were interrupted using double-stop technique in (71%). In 212/306 (52%) a CMAP was utilized. At the end of the procedure PNI persistent in 45% of patients. Fluoroscopic or sonographic evaluation of PNI was performed 1–3 days after the procedure and revealed persistent PNI in 35% of patients. Dyspnea before discharge was reported in 18% of patients with persistent PNI. Patients follow up at 1–3, and 6–12 months included fluoroscopy and a visit in an outpatient clinic. After 1–3 months 18% of patients showed persistent PNI including 13% of patients complaining of dyspnea. After 6–12 months of follow-up including fluoroscopic evaluation PNI was persistent in 1.8% of patients while dyspnea was reported by 1.7% patients. Only 0.08% of the overall population of 13693 patients showed permanent and symptomatic PNI. Conclusion The incidence of PNI during CB2-based PVI is low. About 55% of PNI recovered until the end of the procedure. Most of PNI recovered within 12 months. Symptomatic permanent PNI is very rare in patients after CB2/CB3-based PVI.

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