Novel Technique to Prevent Phrenic Nerve Injury During Pulmonary Vein Isolation Using Preprocedural Imaging

INTRODUCTION: Phrenic nerve (PN) injury is one of the major complications of pulmonary vein isolation (PVI). Pace mapping for PN capture is routinely used to identify areas with high risk for injury along the anterior border of the right pulmonary veins (PVs). Our aim was to evaluate the feasibility of using preprocedural imaging to identify areas where no PN capture is possible along the anterior border of the right PVs, thus avoiding the need for pace mapping during PVI. METHODS AND RESULTS: It was hypothesized that PN capture along the anterior border of the right PVs does not occur in the area where the right and left atria overlap. Three-dimensional segmentation of both atria was performed on preprocedural magnetic resonance and computed tomography angiograms in 40 patients before undergoing PVI. The area of overlap between the right and left atria was delineated. Image registration was performed during the procedure. Using pacing, regions with and without PN capture were marked along the anterior border of the right PVs. A total of 361 points were tested for PN stimulation (9 ± 4 points/patient). PN capture occurred in 97 out of the 189 points (51%) in the area with no overlap between the right and left atria. No PN capture occurred in the area of overlap (172 points, P< 0.001). CONCLUSION: Delineation of the area of overlap between the right and left atria derived from preprocedural imaging reliably identifies regions where PN pace capture does not occur. Testing for PN stimulation before ablation may not be necessary in these regions.