Intentional pneumothorax avoids collateral damage: Dynamic phrenic nerve mobilization through intrathoracic insufflation of carbon dioxide

Abstract

Intentional pneumothorax with intrathoracic carbon dioxide insufflation and video-assisted thoracoscopy provides direct visualization and reversible displacement of the phrenic nerve, enabling successful and safe ablation of a focal atrial tachycardia without invading the pericardium. Introduction Phrenic nerve injury, with resultant impairment to diaphragmatic function, is a well-recognized and feared complication of catheter ablation. Considering the proximity of the phrenic nerves to multiple cardiac structures critical to arrhythmia initiation and maintenance, it is unsurprising that phrenic nerve injury has been reported after ablation of various arrhythmias. For example, reported incidence of phrenic nerve injury exceeds 11% in trials of catheter ablation of atrial fibrillation utilizing radiographic screening. Although multiple approaches to prevent phrenic nerve injury during ablation have been described, these strategies can be difficult to implement, with unsatisfactory effectiveness and safety profiles. Here we present a case describing a novel technique utilizing an intentional pneumothorax to displace the phrenic nerve, allowing for successful and safe ablation of a focal right atrial tachycardia after other approaches had failed.