Phrenic nerve palsy during right-sided pulmonary veins cryoapplications: new insights from pulmonary vein anatomy addressed by computed tomography



There is still sparse information regarding phrenic nerve palsy (PNP) during the cryoablation of both right-sided pulmonary vein (PV) and its anatomical predictors.


Consecutive patients who had undergone pulmonary vein isolation (PVI) using CB-A and suffered PNP during both right-sided PVs were retrospectively included in our study. Two other groups were then selected among patients who experienced PNP during RIPV application only (group 2) and RSPV application only (group 3).


The incidence of PNI during both right-sided PVs cryoapplications was 2.1%, (32 of 1542 patients). There were no significant clinical differences between the 3 groups. Time from basal temperature to −40 °C significantly differed among the groups for both RIPV (p = 0.0026) and RSPV applications (p = 0.0382). Patients with PNP occurring during RSPV applications had significantly larger RSPV cross-sectional area compared to patients without PNP (p = 0.0116), while in patients with PNP during RIPV application, the angle of RIPV ostium on the transverse plane was significantly smaller compared to patients without PNP (p = 0.0035). The carina width was significantly smaller in patients with PNP occurring during both right-sided PVs cryoapplications compared to patients in which PNP occurred only during one right-sided PV application (p < 0.0001); a cutoff value of 8.5 mm had a sensitivity of 87.3% and a specificity of 75.0%.


PNP in both right-sided PVs applications is a complication that occurred in 2.1% of cases during CB-A. Pre-procedural evaluation of right PVs anatomy might be useful in evaluating the risk of PNP.

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Correspondence to Riccardo Maj.

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Conflict of interest

Prof. de Asmundis, Prof Brugada, and Prof Chierchia have received consulting fees and speaker honoraria from Medtronic. G.B.C. and C. d A. have received compensation for teaching and proctoring purposes from AF solutions Medtronic.

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All procedures performed in the studies involving patients were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Maj, R., Borio, G., Ströker, E. et al. Phrenic nerve palsy during right-sided pulmonary veins cryoapplications: new insights from pulmonary vein anatomy addressed by computed tomography. J Interv Card Electrophysiol 60, 85–92 (2021).

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  • Cryoballoon
  • Phrenic nerve palsy
  • Atrial fibrillation
  • Ablation
  • Right pulmonary vein anatomy