From the Arrhythmia Service, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA.
Circ Arrhythm Electrophysiol. 2015 Aug;8(4):896-904. doi: 10.1161/CIRCEP.115.002818. Epub 2015 May 11.
Arrhythmia origin in close proximity to the phrenic nerve (PN) can hinder successful catheter ablation. We describe our approach with epicardial PN displacement in such instances.
PN displacement via percutaneous pericardial access was attempted in 13 patients (age 49±16 years, 9 females) with either atrial tachycardia (6 patients) or atrial fibrillation triggered from a superior vena cava focus (1 patient) adjacent to the right PN or epicardial ventricular tachycardia origin adjacent to the left PN (6 patients). An epicardially placed steerable sheath/4 mm-catheter combination (5 patients) or a vascular or an esophageal balloon (8 patients) was ultimately successful. Balloon placement was often difficult requiring manipulation via a steerable sheath. In 2 ventricular tachycardia cases, absence of PN capture was achieved only once the balloon was directly over the ablation catheter. In 3 atrial tachycardia patients, PN displacement was not possible with a balloon; however, a steerable sheath/catheter combination was ultimately successful. PN displacement allowed acute abolishment of all targeted arrhythmias. No PN injury occurred acutely or in follow up. Two patients developed acute complications (pleuro-pericardial fistula 1 and pericardial bleeding 1). Survival free of target arrhythmia was achieved in all atrial tachycardia patients; however, a nontargeted ventricular tachycardia recurred in 1 patient at a median of 13 months' follow up.
Arrhythmias originating in close proximity to the PN can be targeted successfully with PN displacement with an epicardially placed steerable sheath/catheter combination, or balloon, but this strategy can be difficult to implement. Better tools for phrenic nerve protection are desirable.
起源于膈神经（PN）附近的心律失常会阻碍导管消融的成功。我们描述了在这种情况下通过心外膜 PN 移位来实现的方法。
在 13 例患者中尝试经皮心包穿刺进行 PN 移位，这些患者存在以下情况：靠近右侧 PN 的房性心动过速（6 例）或上腔静脉靶点触发的心房颤动（1 例），或靠近左侧 PN 的心外膜室性心动过速起源（6 例）。最终成功使用心外膜放置的可操纵护套/4mm 导管组合（5 例）或血管或食管球囊（8 例）。球囊放置通常很困难，需要通过可操纵护套进行操作。在 2 例室性心动过速病例中，只有当球囊直接置于消融导管上方时，才能实现 PN 捕获。在 3 例房性心动过速患者中，使用球囊无法实现 PN 移位；然而，最终使用可操纵护套/导管组合成功。PN 移位可使所有目标心律失常立即消除。无 PN 损伤在急性或随访中发生。2 例患者发生急性并发症（1 例胸腔心包瘘和 1 例心包出血）。所有房性心动过速患者均实现了无目标心律失常的生存，但 1 例患者在中位 13 个月的随访中出现了非目标室性心动过速复发。
起源于 PN 附近的心律失常可以通过放置在心外膜上的可操纵护套/导管组合或球囊来成功靶向 PN 移位，但这种策略可能难以实施。需要更好的 PN 保护工具。
