Phrenic nerve paralysis during cryoballoon ablation for atrial fibrillation: A comparison between the first- and second- generation balloon Ruben Casado-Arroyo, MD, Gian-Battista Chierchia, MD, Giulio Conte, MD, Moisés Levinstein, MD, Juan Sieira, MD, Moises Rodriguez-Mañero, MD, Giacomo di Giovanni, MD, Yannis Baltogiannis, MD, Kristel Wauters, MD, Carlo de Asmundis, MD, PhD, Andrea Sarkozy, MD, PhD, Pedro Brugada, MD, PhD From the Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium. BACKGROUND Phrenic nerve palsy (PNP) is the most frequently observed complication during cryoballoon ablation (CB; Arctic Front, Medtronic, MN) occurring in roughly 7%–9% of the cases. The new second-generation cryoballoon ablation Arctic Front Advance (CB-A) (Arctic Front) has recently been launched in the market. OBJECTIVE To evaluate the incidence of right PNP with the new CB-A in comparison with the first-generation balloon in a series of consecutive patients that underwent pulmonary vein isolation with this modality. METHODS The study was designed as an observational study with a prospective follow-up. In total, 121 consecutive patients were included: 80 patients with the CB (group 1) and 41 with the CB-A (group 2). RESULTS Mean procedural times, fluoroscopic times, and time to pulmonary vein isolation documented by real-time recordings were significantly lower in group 2 (P ≤ .05). The occurrence of PNP was significantly higher in group 2 (6.25% [5 of 80] in group 1 vs 19.5% [8 of 41] in group 2; P ¼ .033). At 7 months, PNP persisted in 1 (2.5%) patient in the CB-A group. CONCLUSIONS Right PNP seems to occur in a significantly larger number of patients with the second-generation CB-A. However, this complication is reversible in nearly all cases on short-term follow- up. More refined phrenic nerve monitoring during right-sided pulmonary vein ablation and less vigorous wedging maneuvers in the pulmonary vein ostia might significantly reduce the occurrence of this complication. KEYWORDS Cryoballoon; Ablation; Atrial fibrillation; Complication; Pulmonary vein isolation; Phrenic nerve paralysis ABBREVIATIONS AAD ¼ antiarrhythmic drug treatment; AF ¼ atrial fibrillation; CB ¼ cryoballoon ablation; CB-A ¼ cryoballoon ablation Arctic Front Advance; EGD ¼ esohagogastro- duodenoscopy; PN ¼ phrenic nerve; PNP ¼ phrenic nerve palsy; PV ¼ pulmonary vein; PVI ¼ pulmonary vein isolation; RIPV ¼ right inferior pulmonary vein; RSPV ¼ right superior pulmonary vein; SVC ¼ superior vena cava (Heart Rhythm 2013;10:1318–1324) I 2013 Heart Rhythm Society. All rights reserved. Introduction Phrenic nerve palsy (PNP) is the most frequently observed complication during cryoballoon ablation (CB) (Arctic Front, Medtronic, MN) for drug-resistant atrial fibrillation (AF). 1,2 Recent articles state that this complication occurs in approximately 7%–9% of the procedures, 1,3 although, vir- tually always reversible, cases of permanent PNP have been reported. Recent developments have led to the launch of the second-generation CB Arctic Front Advance (CB-A) (Medtronic) in the market. Owing to significant technolog- ical improvements, this new tool permits a more homoge- neous circumferential lesion around the pulmonary vein (PV) ostium if compared to the previous generation CB. 4 We hope that this will lead to higher rates of permanent PVI and therefore better clinical outcome. However, little is known about the rate of PNP during ablation with the CB-A. The aim of the present study was to compare the incidence, the clinical features, and the outcome of PNP between patients having undergone pulmonary vein isolation (PVI) with the first-generation CB or the second-generation CB-A. Methods Patient population The study was designed as a retrospective study of patients discharged from the Heart Rhythm Management Center, Free University of Brussels, Belgium. A total of 121 consecutive patients admitted to our hospital for CB were Dr Chierchia, Dr Sarkozy, and Dr de Asmundis have received compensation for teaching purposes from AF Solutions and Medtronic. Dr Chierchia has received compensation for proctoring purposes from AF Solutions and Medtronic. Dr Brugada has received speaker fees from Medtronic. Address reprint requests and correspondence: Dr Ruben Casado-Arroyo, Heart Rhythm Management Centre, Universitair Zieken- huis Brussel, Vrije Universiteit Brussel, 101 Laarbeeklaan, Brussels 1090, Belgium. E-mail address: rbcasado@gmail.com. The first 2 authors contributed equally to this work. 1547-5271/$-see front matter B 2013 Heart Rhythm Society. All rights reserved. http://dx.doi.org/10.1016/j.hrthm.2013.07.005