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Chitrala S, Butta N, Immadisetty SK, Suvvari TK, Thomas V. Unilateral Phrenic Nerve Palsy as a Presentation of Diabetes Mellitus: A Rare Case Report. Clin Med Insights Endocrinol Diabetes 2023; 16:11795514231189038. [PMID: 37529302 PMCID: PMC10387670 DOI: 10.1177/11795514231189038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
Diabetes mellitus is one of the most debilitating diseases, diabetic neuropathy happens to be the most common and perhaps the most serious complication of diabetes mellitus, often leading to morbidity and mortality. A 60 year old female presented with disorientation, history of vomiting, shortness of breath, respiratory failure initially. Blood reports revealed that she was positive for ketone bodies with elevated HbA1c and general random blood sugar. Chest radiogram revealed atelectasis of the right lung with prominent involvement of right middle and lower lobes. High-resolution computed tomography of chest confirmed the findings and unilateral diaphragmatic paralysis due to phrenic nerve neuropathy due to undetected type 2 diabetes was diagnosed. Although phrenic nerve paralysis is a rare occurrence with diabetes, the possibility shouldn't be overlooked as a presentation of diabetes mellitus.
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Affiliation(s)
- Sruthi Chitrala
- Department of General Medicine, Nimra Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India
| | - Nikhil Butta
- Department of General Medicine, Guntur Medical College, Guntur, Andhra Pradesh, India
| | - Sandeep Kumar Immadisetty
- Department of General Medicine, Nimra Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India
| | | | - Vimal Thomas
- Tbilisi State Medical University, Tbilisi, Georgia
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Farooq F, Wierzejski WT. Erector Spinae Plane Block as the Phrenic Nerve Sparing Anaesthetic Technique for Shoulder Arthroplasty. Cureus 2023; 15:e41220. [PMID: 37525779 PMCID: PMC10387355 DOI: 10.7759/cureus.41220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/02/2023] Open
Abstract
The utilization of the brachial plexus block has become commonplace in shoulder replacement surgery and the management of postoperative pain. Nonetheless, this technique carries risks, including the occurrence of phrenic nerve palsy and subsequent postoperative dyspnea. In light of these concerns, the erector spinae plane block emerges as a safe, simple, and effective alternative for shoulder surgery with reduced risk of phrenic nerve palsy and potential motor sparing in the affected limb. This research endeavors to elucidate the analgesic application of erector spinae plane block (ESPB) through the presentation and analysis of two cases involving reverse shoulder arthroplasty.
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Affiliation(s)
- Fahad Farooq
- Department of Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
- Graduate School of Medicine, University of Wollongong, Wollongong, AUS
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Coşkunpınar M, Erdoğdu B, Goker H. Asymptomatic unilateral phrenic nerve palsy after bortezomib treatment in a newly diagnosed multiple myeloma patient. J Oncol Pharm Pract 2023; 29:502-505. [PMID: 35786085 DOI: 10.1177/10781552221112151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Bortezomib is the first chemotherapeutic agent of proteosome inhibitor class that can be used in newly diagnosed and relapsed/refractory multiple myeloma. It is well known that bortezomib has side effects such as peripheral sensory, motor, or autonomic neuropathy. In this paper, we will present our patient who developed unilateral phrenic nerve palsy as an autonomic neuropathy after six cycles of subcutaneous bortezomib treatment. This case differs from other cases in that our patient was asymptomatic. CASE REPORT A 57-year-old male patient was admitted with back pain and gait disturbances. In the thorax computed tomography, a soft tissue mass causing compression on the spinal canal was observed in the T12 vertebra. Bone biopsy pathology report resulted in diffuse plasma cell infiltration. The patient was diagnosed with stage ISS-3, IgG kappa type multiple myeloma. MANAGEMENT AND OUTCOME Subcutaneous bortezomib 1 × 2.2 mg (Days 1-4-8-11) + intravenous cyclophosphamide 1000 mg (Day 1) + intravenous dexamethasone 40 mg (Days 1-2-3-4) (VCD chemotherapy protocol) was started. Totally six cycles of VCD were administered. While the patient did not have any respiratory symptoms, an elevation consistent with phrenic nerve palsy was observed in the left hemidiaphragm in the thorax computed tomography that was taken during the preparation for autologous hematopoietic stem cell transplantation. DISCUSSION Bortezomib is a frequently used chemotherapeutic agent in patients with multiple myeloma and care should be taken in terms of the risk of developing phrenic nerve palsy in patients. There are cases of autonomic neuropathy developing after bortezomib treatment.
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Affiliation(s)
- Muharrem Coşkunpınar
- Department of Internal Medicine, 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Batuhan Erdoğdu
- Department of Hematology, 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hakan Goker
- Department of Hematology, 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
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Bohnen M, Weber R, Minners J, Eichenlaub M, Jadidi A, Müller-Edenborn B, Neumann FJ, Arentz T, Lehrmann H. 3D mapping of phrenic nerve course for radiofrequency pulmonary vein isolation. J Cardiovasc Electrophysiol 2023; 34:90-98. [PMID: 36217994 DOI: 10.1111/jce.15703] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Phrenic nerve (PN) injury is a rare but severe complication of radiofrequency (RF) pulmonary vein isolation (PVI). The objective of this study was to characterize the typical intracardiac course of the PN with a three-dimensional electroanatomic mapping system, to quantify the need for modification of the ablation trajectory to avoid delivering an ablation lesion on sites with PN capture, and to identify very circumscribed areas of common PNC on the routine ablation trajectory of a RF-PVI, allowing fast and effective PN screening for everyday usage. METHODS We enrolled 137 consecutive patients (63 ± 9 years, 64% men) undergoing PVI. A detailed high output (20 mA) pace-mapping protocol was performed in the right (RA) and left atrium (LA) and adjacent vasculature. RESULTS The right PN was most commonly captured in the superior vena cava at a lateral (50%) or posterolateral (23%) position before descending along the RA either straight (29%) or with a posterolateral bend (20%). In the LA, beginning deep within the right superior pulmonary vein (RSPV), the right PN is most frequently detectable anterolateral (31%), then descends to the lateral proximal RSPV (23%), and further towards the lateral antral region (15%) onto the medial LA wall (12%). To avoid delivering an ablation lesion on sites with PN capture, modification of ablation trajectory was necessary in 23% of cases, most commonly in the lateral RSPV antrum (81%). No PN injury occurred. CONCLUSION PN mapping frequently reveals the close proximity of the PN to the ablation trajectory during PVI, particularly in the lateral RSPV antrum. Routine PN pacing should be considered during RF PVI procedures.
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Affiliation(s)
- Marius Bohnen
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Reinhold Weber
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Jan Minners
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Martin Eichenlaub
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Amir Jadidi
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Björn Müller-Edenborn
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Thomas Arentz
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Heiko Lehrmann
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
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Ohashi T, Mano T, Iguchi N, Nanaura H, Kiriyama T, Sugie K. [A case of Guillain-Barré syndrome with unilateral diaphragmatic nerve palsy that was longitudinally evaluated using multiple examinations]. Rinsho Shinkeigaku 2022; 62:805-809. [PMID: 36184413 DOI: 10.5692/clinicalneurol.cn-001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The patient, a 50-year-old woman, presented with fever and diarrhea in early July, X. One week later, she noticed muscle weakness in both lower extremities, which upon examination was found to be dominant in the distal muscles, with associated loss of tendon reflexes. We diagnosed the case as Guillain-Barré syndrome. After admission, the patient experienced decreased oxygenation, and a chest X-ray indicated elevation of the left hemidiaphragm. The phrenic nerve conduction studies revealed laterality of the amplitude of compound muscle action potential, and diaphragmatic ultrasonographic examination revealed decreased left diaphragmatic wall motion. We diagnosed the patient with unilateral diaphragmatic nerve palsy and initiated intravenous immunoglobulin and methylprednisolone treatment. After 2 weeks, the patient demonstrated good clinical recovery, increased diaphragmatic nerve amplitude, and improved diaphragmatic movement. We evaluated the longitudinal clinical course of unilateral diaphragmatic nerve palsy in the patient using nerve conduction tests and diaphragmatic echocardiography. The longitudinal evaluation allowed us to assess the pathological condition more sensitively so that the prognosis could be predicted accurately.
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Affiliation(s)
| | - Tomoo Mano
- Department of Neurology, Nara Medical University
- Department of Rehabilitation Medicine, Nara Medical University
| | | | | | | | - Kazuma Sugie
- Department of Neurology, Nara Medical University
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Ichikawa Y, Yanagi S, Ueda H. Transient phrenic nerve palsy induced by cardiac catheterisation in an infant. Cardiol Young 2022; 32:827-9. [PMID: 34521488 DOI: 10.1017/S1047951121003863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report on a 7-month-old male with transient phrenic nerve palsy induced by diagnostic cardiac catheterisation. The phrenic nerve palsy, which is a rare complication, was due to extravascular bleeding from a branch of the internal mammary artery.
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Mol D, Renskers L, Balt JC, Bhagwandien RE, Blaauw Y, van Driel VJHM, Driessen AHG, Elvan A, Folkeringa R, Hassink R, Hooft van Huysduynen B, Luermans JGLM, Stevenhagen JY, van der Voort PH, Westra SW, de Groot JR, de Jong JSSG. Persistent Phrenic Nerve Palsy after Atrial Fibrillation Ablation: Follow-up Data from the Netherlands Heart Registration. J Cardiovasc Electrophysiol 2022; 33:559-564. [PMID: 35040534 PMCID: PMC9303579 DOI: 10.1111/jce.15368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/07/2021] [Accepted: 01/09/2022] [Indexed: 11/28/2022]
Abstract
Background Persistent phrenic nerve palsy (PNP) is an established complication of atrial fibrillation (AF) ablation, especially during cryoballoon and thoracoscopic ablation. Data on persistent PNP reversibility is limited because most patients recover <24 h. This study aims to investigate persistent PNP recovery, freedom of PNP‐related symptoms after AF ablation and identify baseline variables associated with the occurrence and early PNP recovery in a large nationwide registry study. Methods In this study, we used data from the Netherlands Heart Registration, comprising data from 9549 catheter and thoracoscopic AF ablations performed in 2016 and 2017. PNP data was available of 7433 procedures, and additional follow‐up data were collected for patients who developed persistent PNP. Results Overall, the mean age was 62 ± 10 years, and 67.7% were male. Fifty‐four (0.7%) patients developed persistent PNP and follow‐up was available in 44 (81.5%) patients. PNP incidence was 0.07%, 0.29%, 1.41%, and 1.25%, respectively for patients treated with conventional‐RF, phased‐RF, cryoballoon, and thoracoscopic ablation respectively. Seventy‐one percent of the patients fully recovered, and 86% were free of PNP‐related symptoms after a median follow‐up of 203 (113–351) and 184 (82–359) days, respectively. Female sex, cryoballoon, and thoracoscopic ablation were associated with a higher risk to develop PNP. Patients with PNP recovering ≤180 days had a larger left atrium volume index than those with late or no recovery. Conclusion After AF ablation, persistent PNP recovers in the majority of patients, and most are free of symptoms. Female patients and patients treated with cryoballoon or thoracoscopic ablation are more prone to develop PNP.
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Affiliation(s)
- Daniel Mol
- OLVG, Department of Cardiology, Amsterdam, the Netherlands.,Amsterdam University Medical Centres/University of Amsterdam, Department of Cardiology and Cardiac Surgery, Amsterdam, the Netherlands
| | | | - Jippe C Balt
- St. Antonius, Department of Cardiology, Nieuwegein, the Netherlands
| | - Rohit E Bhagwandien
- Erasmus Medical Centre, Department of Cardiology, Rotterdam, the Netherlands
| | - Yuri Blaauw
- University Medical Centre Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | - Antoine H G Driessen
- Amsterdam University Medical Centres/University of Amsterdam, Department of Cardiology and Cardiac Surgery, Amsterdam, the Netherlands
| | - Arif Elvan
- Isala, Department of Cardiology, Zwolle, the Netherlands
| | - Richard Folkeringa
- Medical Centre Leeuwarden, Department of Cardiology, Leeuwarden, the Netherlands
| | - Rutger Hassink
- University Medical Centre Utrecht, Department of Cardiology, Utrecht, the Netherlands
| | | | - Justin G L M Luermans
- Maastricht University Medical Centre, Department of Cardiology, Maastricht, the Netherlands
| | | | - Pepijn H van der Voort
- Catharina Hospital, Department of Cardiology and Cardiac Surgery, Eindhoven, the Netherlands
| | - Sjoerd W Westra
- Radboud University Medical Centre, Department of Cardiology, Nijmegen, the Netherlands
| | - Joris R de Groot
- Amsterdam University Medical Centres/University of Amsterdam, Department of Cardiology and Cardiac Surgery, Amsterdam, the Netherlands
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- OLVG, Department of Cardiology, Amsterdam, the Netherlands
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Pott A, Wirth H, Teumer Y, Weinmann K, Baumhardt M, Schweizer C, Markovic S, Buckert D, Bothner C, Rottbauer W, Dahme T. Predicting Phrenic Nerve Palsy in Patients Undergoing Atrial Fibrillation Ablation With the Cryoballoon-Does Sex Matter? Front Cardiovasc Med 2022; 8:746820. [PMID: 34970602 PMCID: PMC8712427 DOI: 10.3389/fcvm.2021.746820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Phrenicus nerve palsy (PNP) is a typical complication during pulmonary vein isolation (PVI) using the cryoballoon with the ominous potential to counteract the clinical benefit of restored sinus rhythm. According to current evidence incidence of PNP is about 5–10% of patients undergoing Cryo-PVI and is more frequent during ablation of the RSPV compared to the RIPV. However, information on patient specific characteristics predicting PNP and long-term outcome of patients suffering from this adverse event is sparse. Aim of the Study: To evaluate procedural and clinical characteristics of AF patients with PNP during cryoballoon PVI compared to patients without PNP. Methods and Results: Between 2013 and 2019 we included 632 consecutive AF patients undergoing PVI with the cryoballoon in our study. 84/632 (13.3%) patients experienced a total number of 89 PNP during the ablation procedure. 75/89 (84%) cryothermal induced PNP recovered until the end of the procedure (transient PNP, tPNP), whereas 14/89 (16%) PNP hold beyond the end of the procedure (non-transient PNP, ntPNP). Using multivariate logistic regression, we found that sex and BMI are strong and independent predictors of cryothermal induced non-transient PNP during cryoballoon PVI with an odds ratio of 3.9 (CI: 95%, 1.1–14.8, p = 0.04) for female gender. Interestingly, all patients (14/14, 100%) with a non-transient PNP experienced complete PNP resolution after a mean recovery time of 68 ± 79 days. Conclusion: Our data indicate for the first time, that female sex and lower BMI are independent predictors for non-transient PNP caused by cryoballoon PVI. Fortunately, during follow up all PNP patients resolved completely with a median recovery time of 35 days.
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Affiliation(s)
- Alexander Pott
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Hagen Wirth
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Yannick Teumer
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Karolina Weinmann
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Michael Baumhardt
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | | | - Sinisa Markovic
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Dominik Buckert
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Carlo Bothner
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | | | - Tillman Dahme
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
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Nardini M, Jayakumar S, Migliore M, Nosotti M, Paul I, Dunning J. Minimally Invasive Plication of the Diaphragm: A Single-Center Prospective Study. Innovations (Phila) 2021; 16:343-349. [PMID: 34130535 DOI: 10.1177/15569845211011583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Plication of the diaphragm is a life-changing procedure for patients affected by diaphragm paralysis. Traditionally, this procedure is performed through a thoracotomy. Access to the diaphragm via this incision is poor and the indications for surgery are limited to patients who can actually sustain such an invasive approach and associated morbidities. A minimally invasive approach was developed to improve the surgical management of diaphragm paralysis. METHODS Patients underwent minimally invasive diaphragm plication either by video-assisted or robotic surgery through a 3-port technique with CO2 insufflation. Patients were followed at the routine 6-week clinic and also by telephone consultation 6 to 12 months postoperatively. Data were collected on postoperative complications, postoperative pain or numbness, symptomatic improvement, and change to quality of life following surgery. RESULTS Forty-eight patients underwent 49 minimally invasive diaphragm plication. Median postoperative length of hospital stay was 4 days (range: 2 to 34 days) and there were no cases of mortality. Mean reduction in Medical Research Council dyspnea score per patient was 2.2 points (mode: 3 points). Twenty-eight patients (77.8%) reported a significant symptomatic improvement enabling improvements in quality of life, and 97.2% (n = 35) were satisfied with the surgical outcome. CONCLUSIONS Minimally invasive diaphragm plication is a safe procedure associated with prompt postoperative recovery. It is effective at reducing debilitating dyspnea and improving quality of life.
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Affiliation(s)
- Marco Nardini
- 9304 Department of Thoracic Surgery and Lung Transplantation, University of Milan, Italy.,4964 Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Shruti Jayakumar
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Marcello Migliore
- 8903 Department of Thoracic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mario Nosotti
- 9304 Department of Thoracic Surgery and Lung Transplantation, University of Milan, Italy
| | - Ian Paul
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Joel Dunning
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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Abstract
We present a case of a woman who received a left single-injection supraclavicular brachial plexus block for analgesia to facilitate upper extremity orthopaedic surgery. Before tracheal extubation she desaturated, was noted to have a low tidal volume and reduced left-sided air entry on auscultation of the chest. A chest x-ray taken 1 h following tracheal extubation revealed elevation of the left hemidiaphragm and a rightward shift of the trachea and mediastinal structures, with no evidence of pneumothorax. Findings were in-keeping with phrenic nerve palsy complicating the brachial plexus block performed. The patient was asymptomatic and discharged home the next day following repeat chest x-rays. We believe this is the first report of tracheal deviation contralateral to the side of an elevated hemidiaphragm secondary to phrenic nerve palsy from a brachial plexus block.
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Affiliation(s)
- J Querney
- Department of Anesthesia and Perioperative Medicine Western University London Ontario Canada
| | - S I Singh
- Department of Anesthesia and Perioperative Medicine Western University London Ontario Canada
| | - I Sebbag
- Department of Anesthesia and Perioperative Medicine Western University London Ontario Canada
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Wang L, Liu T, Liu Z. Chronic respiratory dysfunction due to diaphragmatic paralysis following penetrating neck trauma: A case report. Medicine (Baltimore) 2021; 100:e24043. [PMID: 33530199 PMCID: PMC7850730 DOI: 10.1097/md.0000000000024043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/27/2020] [Accepted: 12/07/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Respiratory dysfunction resulting from unilateral diaphragmatic paralysis during neck trauma is very rare in adults. We describe the symptoms, diagnosis and treatment of 1 patient with chronic respiratory insufficiency, in whom the diaphragmatic paralysis was associated with phrenic nerve injury due to penetrating neck trauma. PATIENT CONCERNS A 50-year-old worker was admitted because of left penetrating neck trauma. Imaging investigations demonstrated elevation of the left hemidiaphragm and the C5 and C6 roots avulsion. He complained of gradually worsening dyspnea on exertion 2 months later. DIAGNOSES The patient was diagnosed with chronic respiratory dysfunction secondary to diaphragmatic paralysis, which caused by phrenic nerve injury. INTERVENTIONS A conventional video-assisted thoracoscopic diaphragm plication was performed after failed conservative management. OUTCOMES The respiratory status improved markedly, and he did well without recurrence until 2 years' follow-up. LESSONS The possibilities of phrenic nerve palsy and diaphragmatic paralysis should not be overlooked during the evaluation of neck trauma.
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Affiliation(s)
- Lian Wang
- Department of Thoracic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Tianshu Liu
- Department of Thoracic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Zhihai Liu
- Department of Critical Care Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
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12
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Abstract
RATIONALE Bilateral brachial plexus block (BPB) generally requires a relatively large dose of local anesthetic for a successful block, resulting in a high risk of local anesthetic systemic toxicity. It can also result in inadvertent bilateral phrenic nerve palsy, leading to respiratory failure. Hence, it has not been widely used. However, it can be performed in selected patients. In this report, we present a case of ultrasound-guided BPB for bilateral upper extremity surgery in a patient with cervical spinal cord injury (SCI). PATIENT CONCERNS A 25-year-old woman with SCI secondary to traumatic fifth cervical spine fracture scheduled for surgical treatment of bilateral elbow fracture received bilateral BPB. DIAGNOSES Due to the complications of SCI, the patient had incomplete sensory loss, loss of motor function, and complete diaphragmatic paralysis on the right side. INTERVENTIONS Right infraclavicular and left axillary BPB was performed as the sole anesthetic procedure for bilateral upper extremity surgery. OUTCOMES Bilateral BPB was successful for bilateral upper extremity surgery. The surgery was uneventful and without further complications. LESSONS Patients with cervical SCI have a high risk of respiratory complications. Bilateral BPB can be a suitable option for bilateral upper extremity surgery in selected patients. It is imperative to select an appropriate anesthetic technique that preserves respiratory function to minimize the potential risk of respiratory complications.
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Ravi V, Poudyal A, Pulipati P, Larsen T, Krishnan K, Trohman RG, Sharma PS, Huang HD. A systematic review and meta-analysis comparing second-generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2559-2571. [PMID: 32671920 DOI: 10.1111/jce.14676] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the preferred modalities for catheter ablation of atrial fibrillation (AF). Technological advances have improved procedural outcomes, warranting an updated comparison. We sought to evaluate the efficacy and safety of CBA-2nd generation (CBA-2G) in comparison to RFA-contact force (RFA-CF) in patients with AF. METHODS MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 03/01/2020 for relevant studies comparing CBA-2G versus RFA-CF in patients undergoing initial catheter ablation for AF. RESULTS A total of 17 studies, involving 11 793 patients were included. There was no difference between the two groups in the outcomes of freedom from atrial arrhythmia (p = .67) and total procedural complications (p = .65). There was a higher incidence of phrenic nerve palsy in CBA-2G (odds ratio: 10.7; 95% confidence interval [CI]: 5.85 to 19.55; p < .001). Procedure duration was shorter (mean difference: -31.32 min; 95% CI: -40.73 to -21.92; p < .001) and fluoroscopy duration was longer (+3.21 min; 95% CI: 1.09 to 5.33; p = .003) in CBA-2G compared to RFA-CF. In the subgroup analyses of patients with persistent AF and >1 freeze lesion delivered per vein, there was no difference in freedom from atrial arrhythmia. CONCLUSIONS In AF patients undergoing initial ablation, CBA-2G and RFA-CF were equally efficacious. The procedure duration was shorter, but with a higher incidence of phrenic nerve palsy in CBA-2G. In patients with persistent AF, there was no difference in the efficacy between CBA-2G or RFA-CF techniques.
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Affiliation(s)
- Venkatesh Ravi
- Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Abhushan Poudyal
- Division of Cardiology, Department of Medicine, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Priyanjali Pulipati
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Timothy Larsen
- Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Kousik Krishnan
- Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Richard G Trohman
- Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Parikshit S Sharma
- Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Henry D Huang
- Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
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14
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Apiyo P, Hajek J. Herpes zoster complicated by phrenic nerve palsy and respiratory compromise. Afr Health Sci 2019; 19:2347-2350. [PMID: 32127803 PMCID: PMC7040297 DOI: 10.4314/ahs.v19i3.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Herpes zoster can be associated with severe neurological complications. Case presentation In this article, we describe the case of a 54-year-old man with herpes zoster affecting his right upper chest and neck region complicated by phrenic nerve palsy and respiratory compromise. The diagnosis of herpes zoster was made based on the classic appearance of the rash and associated neuropathic-type pain. The diagnosis of phrenic nerve palsy was made by chest x-ray and ultrasound. Conclusion Clinicians should be aware of the possibility of phrenic nerve palsy occurring in patients who have herpes zoster affecting the region of C3,4,5 dermatomes. Although symptoms of unilateral diaphragmatic paresis are usually mild, in patients with obesity or comorbid lung disease, new onset phrenic nerve palsy can lead to significant respiratory compromise.
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Affiliation(s)
- Paska Apiyo
- Gulu Regional Referral Hospital, Gulu, Uganda
| | - Jan Hajek
- Gulu Regional Referral Hospital, Gulu, Uganda.,University of British Columbia, Vancouver, Canada
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15
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Patel N, Patel K, Shenoy A, Baker WL, Makaryus AN, El-Sherif N. Cryoballoon Ablation for the Treatment of Atrial Fibrillation: A Meta-analysis. Curr Cardiol Rev 2019; 15:230-238. [PMID: 30539701 PMCID: PMC6719384 DOI: 10.2174/1573403x15666181212102419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/25/2018] [Accepted: 12/06/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Ablation therapy is the treatment of choice in antiarrhythmic drugrefractory atrial fibrillation (AF). It is performed by either cryoballoon ablation (CBA) or radiofrequency ablation. CBA is gaining popularity due to simplicity with similar efficacy and complication rate compared with RFA. In this meta-analysis, we compare the recurrence rate of AF and the complications from CBA versus RFA for the treatment of AF. METHODS We systematically searched PubMed for the articles that compared the outcome of interest. The primary outcome was to compare the recurrence rate of AF between CBA and RFA. We also included subgroup analysis with complications of pericardial effusion, phrenic nerve palsy and cerebral microemboli following ablation therapy. RESULTS A total of 24 studies with 3527 patients met our predefined inclusion criteria. Recurrence of AF after CBA or RFA was similar in both groups (RR: 0.84; 95% CI: 0.65, 1.07; I2=48%, Cochrane p=0.16). In subgroup analysis, heterogeneity was less in paroxysmal AF (I2=0%, Cochrane p=0.46) compared to mixed AF (I2=72%, Cochrane p=0.003). Procedure and fluoroscopy time was less by 26.37 and 5.94 minutes respectively in CBA compared to RFA. Complications, pericardial effusion, and silent cerebral microemboli, were not different between the two groups, however, phrenic nerve palsy was exclusively present only in CBA group. CONCLUSION This study confirms that the effectiveness of CBA is similar to RFA in the treatment of AF with the added advantages of shorter procedure and fluoroscopy times.
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Affiliation(s)
- Nirav Patel
- Division of Cardiology, Hartford Hospital, Hartford, CT, United States
| | - Krunalkumar Patel
- Division of Cardiology, North Shore University Hospital, Manhasset, NY, United States
| | - Abhishek Shenoy
- Division of Medicine, University of Virginia, Charlottesville, VA, United States
| | - William L Baker
- Division of Cardiology, Hartford Hospital, Hartford, CT, United States.,Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, United States
| | - Amgad N Makaryus
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY, United States.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Nabil El-Sherif
- Division of Cardiology, Brooklyn VA Center, Brooklyn, NY, United States
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16
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Abbadessa G, Lavorgna L, Cirillo G, Clerico M, Todisco V, Cirillo M, Trojsi F, Tedeschi G, Bonavita S. Right phrenic nerve palsy following transcatheter radiofrequency current atrial fibrillation ablation: Case report. J Int Med Res 2019; 47:3438-3443. [PMID: 31144560 PMCID: PMC6683920 DOI: 10.1177/0300060519849267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Phrenic nerve palsy (PNP) is a well-known complication of cardiac surgery or jugular/subclavian vein catheterization, presenting with cough, hiccups, dyspnoea/shortness of breath and, in some cases, ventilatory failure. Rarely, PNP is a complication of transcatheter radiofrequency ablation for atrial fibrillation. This report describes the case of a 72-year-old woman with a 2-year history of recurrent paroxysmal atrial fibrillation associated with occasional palpitations and shortness of breath who underwent routine transcatheter radiofrequency ablation. Three days after the procedure, the patient developed shortness of breath and progressive dyspnoea. Motor nerve conduction showed the absence of the right phrenic nerve compound motor action potential compared with the normal left side confirming the diagnosis of a right phrenic nerve palsy. This current case demonstrated the importance of undertaking an electrophysiological evaluation of phrenic nerve conduction after transcatheter radiofrequency ablation in patients presenting with palpitations and shortness of breath even if present a few days after the procedure.
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Affiliation(s)
- Gianmarco Abbadessa
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luigi Lavorgna
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Giovanni Cirillo
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy.,2 Laboratory of Human Anatomy and Morphology of Neural Networks, Department of Mental, Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marinella Clerico
- 3 Department of Clinical and Biological Sciences, AOU San Luigi Gonzaga, Orbassano, Italy
| | - Vincenzo Todisco
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Cirillo
- 4 Division of Neuroradiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesca Trojsi
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gioacchino Tedeschi
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Simona Bonavita
- 1 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, I Division of Neurology and Neurophysiopathology, University of Campania Luigi Vanvitelli, Naples, Italy
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17
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Rajapakse NS, Ellsworth K, Liesman RM, Ho ML, Henry N, Theel ES, Wallace A, Alvino ACI, Medeiros de Mello L, Meneses J. Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome. Emerg Infect Dis 2019; 24. [PMID: 30016248 PMCID: PMC6056128 DOI: 10.3201/eid2408.180057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This case series of right unilateral diaphragmatic paralysis suggests peripheral nervous system involvement. Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system. We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.
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18
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Abstract
Phrenic nerve palsy (PNP) is a potential complication of cardiac surgery. It may prolong ventilation and hospitalization and result in significant morbidity and mortality. The diagnosis and management of PNP following cardiac surgery is reviewed.
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Affiliation(s)
- Noura El-Masri
- The Lebanese University School of Medicine, Al-Hadath, Lebanon
| | - Fatima Saj
- The Lebanese University School of Medicine, Al-Hadath, Lebanon
| | - Tarek Wehbe
- The Lebanese Canadian and The Notre Dame University Hospitals, Department of Hematology, Jounieh, Lebanon
| | - Georges Nasrallah
- The Notre Dame University Hospital, Chief of Cardiothoracic Anesthesia, Jounieh, Lebanon
| | - Sarkis Ejbeh
- The Notre Dame University Hospital, Chief of Cardiothoracic Surgery, Jounieh, Lebanon
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19
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Martirosyan M, Caliskan K, Kik C, Szili-Torok T. Left Diaphragmatic Hemiparesis: An Unexpected Complication of Transvenous Lead Extraction. JACC Clin Electrophysiol 2018; 3:1197-1199. [PMID: 29759507 DOI: 10.1016/j.jacep.2017.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/24/2017] [Accepted: 02/02/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Mihran Martirosyan
- Department of Clinical Electrophysiology, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Department of Heart Failure/Heart Transplantation, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Clinical Electrophysiology, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands.
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20
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Santoro F, Metzner A, Ouyang F, Kuck KH, Rillig A. How to Pace Phrenic Nerve in Congenital Persistent Left Superior Caval Vein and Atresia of Right Superior Caval Vein? JACC Clin Electrophysiol 2018; 4:282-3. [PMID: 29749952 DOI: 10.1016/j.jacep.2017.09.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 09/27/2017] [Indexed: 11/23/2022]
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21
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Chierchia GB, Iacopino S, de Asmundis C. Cryoballoon Ablation in Today's Practice: Can the Left Common Ostium Be Ablated and Injury to the Right Phrenic Nerve Avoided? Arrhythm Electrophysiol Rev 2017; 6:156-158. [PMID: 29326828 DOI: 10.15420/aer.2017.6.4eo2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cryoballoon ablation is rapidly gaining popularity among electrophysiologists in the setting of pulmonary vein isolation for the treatment of AF. The first part of the following review focuses on the feasibility and clinical outcome of this technique in patients exhibiting a left common ostium. In the second part, we discuss how to predict and prevent the most common complication related to cryoballoon ablation: right phrenic nerve palsy.
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Affiliation(s)
| | - Saverio Iacopino
- Electrophysiology Unit, Villa Maria Cecilia Hospital,Ravenna, Italy
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, University of Brussels,Brussels, Belgium
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22
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Nguyen DT, Gerstenfeld EP, Tzou WS, Jurgens PT, Zheng L, Schuller J, Zipse M, Sauer WH. Radiofrequency Ablation Using an Open Irrigated Electrode Cooled With Half-Normal Saline. JACC Clin Electrophysiol 2017; 3:1103-1110. [PMID: 29759492 DOI: 10.1016/j.jacep.2017.03.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/11/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study evaluated the use of half-normal saline (HNS) as the radiofrequency ablation (RFA) cooling irrigant. BACKGROUND Some instances of ventricular arrhythmia may originate deep within myocardium and can be refractory to standard ablation using open irrigated RFA. Recent data suggest that deeper ablation lesions can be created by decreasing the irrigant ionic concentration delivered through open irrigated RFA than by using normal saline (NS). METHODS Bovine myocardium was placed in a circulating saline bath. Two RFA catheters were oriented across from each other, with myocardium in between. Sequential unipolar HNS-irrigated RFA was performed and compared to bipolar ablation by using NS or HNS. Unipolar HNS ablation of the ventricles in a porcine model was performed and compared to ablation using NS. RESULTS Sequential ex vivo unipolar RFA with HNS produced larger lesions than sequential unipolar RFA with NS and produced lesions of similar size to those created with bipolar RFA using NS. Ex vivo bipolar RFA using HNS created the largest lesions. In vivo unipolar HNS ablation in porcine endocardium created larger lesion volumes, 152.9 ± 29.2 μl, compared to 94.7 ± 33.4 μl for unipolar ablation using NS. CONCLUSIONS By decreasing ionic concentration and charge density in RFA using HNS instead of NS irrigant, larger ablation lesions can be created and are similar in size to lesions created using bipolar ablation. This may be a useful ablation strategy for deep myocardial circuits refractory to standard ablation. Further studies are needed to evaluate this novel RFA strategy.
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Affiliation(s)
- Duy T Nguyen
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco, San Francisco, California
| | - Wendy S Tzou
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Paul T Jurgens
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Lijun Zheng
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Joseph Schuller
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Matthew Zipse
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - William H Sauer
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
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23
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Abstract
Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm. In one case, a 30 year male complained of chronic dull aching chest pain, and hoarseness of voice; posteroanterior view chest radiograph revealed large spherical radiopacity on the left upper lung zone with smooth lobulated margin with elevated left hemidiaphragm. On Colour Doppler sonography, lesion was anechoic on gray scale sonography but on Doppler analysis revealed intense internal vascularity within it with characteristic “Ying Yang” sign. The finding favor the vascular origin of the lesion and a diagnosis of an arterial aneurysm was made Contrast-enhanced computed tomography (CT) of the thorax revealed a large well defined spherical lesion of 8 × 10 cm size with smooth well defined margin arising from the aortic arch and attenuation of impending rupture or dissection were lesion on immediate post contrast and delayed scan was similar to that of aorta. Left hemidiaphragm elevation was explained by the gross mass effect of the aneurysm causing right phrenic nerve palsy.
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Affiliation(s)
- Md Arshad Ejazi
- Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Md Mazhar Alam
- Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Mohammad Shameem
- Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Rakesh Bhargava
- Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - C G Adil Wafi
- Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Salauddin
- Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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Abstract
INTRODUCTION Idiopathic phrenic nerve palsy is a rare cause of exertional dyspnea. We present a case of a patient presenting with worsening dyspnea of an unknown etiology found to be related to bilateral phrenic nerve palsy. DISCUSSION Forty-two-year-old man presented to our emergency department with exertional dyspnea, orthopnea, and a left lower lobe consolidation treated initially as bronchitis by his primary physician as an outpatient, then subsequently as pneumonia at another institution, with no improvement in symptomatology. After admission to our hospital, CT chest demonstrated only supradiaphragmatic atelectatic changes. Echocardiography was normal. Bronchoscopy was contemplated however the patient could not lie flat. A fluoroscopic sniff test demonstrated diaphragmatic dysfunction and pulmonary function tests revealed restrictive pulmonary disease with evidence of neuromuscular etiology. Nerve conduction studies confirmed bilateral phrenic neuropathy. He was referred to a specialized neuromuscular disease center where subsequent workup did not demonstrate any specific etiology. A sleep study confirmed sleep disordered breathing suggestive of diaphragmatic paralysis and he was discharged on bi-level positive pressure ventilation. CONCLUSION This is a unique case of exertional dyspnea and orthopnea from diaphragmatic paresis caused by bilateral phrenic nerve palsy where the initial workup for pulmonary and cardiovascular etiologies was essentially unremarkable. Shortness of breath and orthopnea caused by phrenic neuropathy is a rare condition, yet has a variety of etiologies. Our case suggests a template to the diagnostic approach, management, and follow up of bilateral phrenic nerve palsy.
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Affiliation(s)
| | | | - Hassan Tariq
- Department of Medicine
- Correspondence: Hassan Tariq, Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave, Suit #10 C, Bronx, NY 10457 (e-mail: )
| | - Trupti Vakde
- Division of Critical Care Medicine, Bronx Lebanon Hospital Center, Bronx, NY
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25
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Abstract
We report a case of reversible diaphragmatic paralysis caused by a malpositioned chest tube, a diagnosis to consider when unexplained respiratory failure occurs following drainage of pleural effusion. Prompt recognition and removal of the tube led to full recovery of diaphragm function.
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26
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Aryana A, Singh SM, Kowalski M, Pujara DK, Cohen AI, Singh SK, Aleong RG, Banker RS, Fuenzalida CE, Prager NA, Bowers MR, D'Avila A, O'Neill PG. Acute and Long-Term Outcomes of Catheter Ablation of Atrial Fibrillation Using the Second-Generation Cryoballoon versus Open-Irrigated Radiofrequency: A Multicenter Experience. J Cardiovasc Electrophysiol 2015; 26:832-839. [PMID: 25917655 DOI: 10.1111/jce.12695] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION There are limited comparative data on catheter ablation of atrial fibrillation (CAAF) using the second-generation cryoballoon (CB-2) versus point-by-point radiofrequency (RF). This study examines the acute/long-term CAAF outcomes using these 2 strategies. METHODS AND RESULTS In this multicenter, retrospective, nonrandomized analysis, procedural and clinical outcomes of 1,196 patients (76% with paroxysmal AF) undergoing CAAF using CB-2 (n = 773) and open-irrigated, non-force sensing RF (n = 423) were evaluated. Pulmonary vein isolation was achieved in 98% with CB-2 and 99% with RF (P = 0.168). CB-2 was associated with shorter ablation time (40 ± 14 min vs. 66 ± 26 min; P < 0.001) and procedure time (145 ± 49 minutes vs. 188 ± 42 minutes; P < 0.001), but greater fluoroscopic utilization (29 ± 13 minutes vs. 23 ± 14 minutes; P < 0.001). While transient (7.6% vs. 0%; P < 0.001) and persistent (1.2% vs. 0%; P = 0.026) phrenic nerve palsy occurred exclusively with CB-2, other adverse event rates were similar between CB-2 (1.6%) and RF (2.6%); P = 0.207. However, freedom from AF/atrial flutter/tachycardia at 12 months following a single procedure without antiarrhythmic therapy was greater with CB-2 (76.6%) versus RF (60.4%); P < 0.001. While this difference was evident in patients with paroxysmal AF (P < 0.001), it did not reach significance in those with persistent AF (P = 0.089). Additionally, CB-2 was associated with reduced long-term need for antiarrhythmic therapy (16.7% vs. 22.0%; P = 0.024) and repeat ablations (14.6% vs. 24.1%; P < 0.001). CONCLUSION In this multicenter, retrospective, nonrandomized study, CAAF using CB-2 coupled with RF as occasionally required was associated with greater freedom from atrial arrhythmias at 12 months following a single procedure without antiarrhythmic therapy when compared to open-irrigated, non-force sensing RF, alone.
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Affiliation(s)
- Arash Aryana
- Regional Cardiology Associates and Dignity Health Heart & Vascular Institute, Sacramento, California, USA
| | - Sheldon M Singh
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Marcin Kowalski
- Division of Cardiac Electrophysiology, Staten Island University Hospital, Staten Island, New York, USA
| | - Deep K Pujara
- Department of Cardiothoracic Surgery, CHI Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, Texas, USA
| | - Andrew I Cohen
- Aurora Denver Cardiology Associates, Aurora, Colorado, USA
| | - Steve K Singh
- Department of Cardiothoracic Surgery, CHI Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, Texas, USA
| | - Ryan G Aleong
- Division of Cardiac Electrophysiology, University of Colorado, Denver, Colorado, USA
| | - Rajesh S Banker
- Hoag Hospital, Newport Beach, CA and University of California Irvine Medical Center, Orange, California, USA
| | | | | | - Mark R Bowers
- Regional Cardiology Associates and Dignity Health Heart & Vascular Institute, Sacramento, California, USA
| | - André D'Avila
- Instituto de Pesquisa em Arritmia Cardiaca (IPAC), Hospital Cardiologico-Florianopolis, Florianopolis, South Carolina, Brazil
| | - Padraig Gearoid O'Neill
- Regional Cardiology Associates and Dignity Health Heart & Vascular Institute, Sacramento, California, USA
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Yoshida K, Kawabata H. The prognostic value of concurrent phrenic nerve palsy in newborn babies with neonatal brachial plexus palsy. J Hand Surg Am 2015; 40:1166-9. [PMID: 25804363 DOI: 10.1016/j.jhsa.2015.01.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 01/29/2015] [Accepted: 01/31/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the prognostic value of concurrent phrenic nerve palsy for predicting spontaneous motor recovery in neonatal brachial plexus palsy. METHODS We reviewed the records of 366 neonates with brachial plexus palsy. The clinical and follow-up data of patients with and without phrenic nerve palsy were compared. RESULTS Of 366 newborn babies with neonatal brachial plexus palsy, 21 (6%) had concurrent phrenic nerve palsy. Sixteen of these neonates had upper-type palsy and 5 had total-type palsy. Poor spontaneous motor recovery was observed in 13 neonates with concurrent phrenic nerve palsy (62%) and in 129 without concurrent phrenic nerve palsy (39%). Among neonates born via vertex delivery, poor motor recovery was observed in 7 of 9 (78%) neonates with concurrent phrenic nerve palsy and 115 of 296 (39%) without concurrent phrenic nerve palsy. CONCLUSIONS Concurrent phrenic nerve palsy in neonates with brachial plexus palsy has prognostic value in predicting poor spontaneous motor recovery of the brachial plexus, particularly after vertex delivery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Kiyoshi Yoshida
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hidehiko Kawabata
- Department of Orthopaedic Surgery, Osaka Medical Center and Research, Osaka, Japan
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28
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Saitoh Y, Irfan G, Ciconte G, Mugnai G, Sieira J, Di Giovanni G, Baltogiannis G, Conte G, Hünük B, Ströker E, Velagić V, Overeinder I, De Asmundis C, Chierchia GB, Brugada P. Persistence of Phrenic Nerve Palsy Following 28-mm Cryoballoon Ablation: A Four-Year Single Center Experience. Pacing Clin Electrophysiol 2015; 38:807-14. [PMID: 25851416 DOI: 10.1111/pace.12636] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 03/24/2015] [Accepted: 03/29/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Phrenic nerve palsy (PNP) is the most frequently observed complication in the setting of cryoballoon (CB) ablation (Arctic Front, Medtronic Inc., Minneapolis, MN, USA). Although, usually transient, resolving before the end of the procedure, persistent PNP (not resolving before the end of procedure) can occur. Literature on persistent PNP after second generation CB ablation is relatively sparse. METHODS A total of 316 consecutive patients having undergone large 28-mm CB ablation as index procedure in the Heart Rhythm Management Center, UZ Brussels, Belgium, from January 2009 to December 2013 were retrospectively reviewed for the study. Of these 117 patients were treated with the first generation CB (CB1) and 199 patients with the second generation CB (CB2). RESULTS PNP occurred in 10% of the total population. Persistent PNP was only observed following CB2 ablation which occurred in 4.5% of the group. At a mean follow-up of 11 months, diaphragmatic contraction in persistent PNP patients resumed in 78% (7/9) of the patients. In a final follow-up at 5 and 20 months, PNP persisted in two patients, respectively. PNP during ablation in the right inferior pulmonary vein was only observed in the CB2 group. No predictors of persistency of PNP were observed. CONCLUSION Persistence of PNP only occurred in the CB2 group in 4.5% of patients. The majority of patients with persistent PNP were asymptomatic. In most of the patients having persistent PNP after ablation, complete phrenic nerve function resumed during follow-up (78%).
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Affiliation(s)
- Yukio Saitoh
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Ghazala Irfan
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Giuseppe Ciconte
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Giacomo Mugnai
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Juan Sieira
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | | | | | - Giulio Conte
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Burak Hünük
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Erwin Ströker
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Vedran Velagić
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Ingrid Overeinder
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | - Carlo De Asmundis
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
| | | | - Pedro Brugada
- From the Heart Rhythm Management Center, UZ Brussel-VUB, Brussels, Belgium
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29
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Huemer M, Wutzler A, Parwani AS, Attanasio P, Haverkamp W, Boldt LH. Mapping of the left-sided phrenic nerve course in patients undergoing left atrial catheter ablations. Pacing Clin Electrophysiol 2014; 37:1141-8. [PMID: 24831508 DOI: 10.1111/pace.12422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 03/03/2014] [Accepted: 04/01/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Catheter ablation of atrial fibrillation has been associated with left-sided phrenic nerve palsy. Knowledge of the individual left phrenic nerve course therefore is essential to prevent nerve injury. The aim of this study was to test the feasibility of an intraprocedural pace mapping and reconstruction of the left phrenic nerve course and to characterize which anatomical areas are affected. METHODS In patients undergoing left atrial catheter ablation, a three-dimensional map of the left atrial anatomical structures was created. The left-sided phrenic nerve course was determined by high-output pace mapping and reconstructed in the map. RESULTS In this study, 40 patients with atrial fibrillation or atrial tachycardias were included. Left phrenic nerve capture was observed in 23 (57.5%) patients. Phrenic nerve was captured in 22 (55%) patients inside the left atrial appendage, in 22 (55%) in distal parts, in 21 (53%) in medial parts, and in two (5%) in ostial parts of the appendage. In three (7.5%) patients, capture was found in the distal coronary sinus and in one (2.5%) patient in the left atrium near the left atrial appendage ostium. Ablation target was changed due to direct spatial relationship to the phrenic nerve in three (7.5%) patients. No phrenic nerve palsy was observed. CONCLUSIONS Left-sided phrenic nerve capture was found inside and around the left atrial appendage in the majority of patients and additionally in the distal coronary sinus. Phrenic nerve mapping and reconstruction can easily be performed and should be considered prior catheter ablations in potential affected areas.
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Affiliation(s)
- Martin Huemer
- Department of Cardiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany
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30
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Abstract
A 36-year-old Indian man, a recently diagnosed case of the right lung carcinoma underwent fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET/CT) for staging of the malignancy. PET/CT showed increased FDG uptake in the right lung mass, consistent with the known primary tumor. Right hemidiaphragm was found to be elevated on CT, suggesting right diaphragmatic paresis. The PET scan demonstrated asymmetric, intense FDG uptake in the left hemidiaphragm and accessory muscles of respiration, which was possibly due to compensatory increased workload related to contralateral right diaphragmatic paresis. The right diaphragmatic paresis was hypothesized to be caused by phrenic nerve palsy by right lung neoplasm.
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Affiliation(s)
- Prathamesh Joshi
- Department of Nuclear Medicine and PET-CT, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
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31
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Jha S, Ansari M, Sonkar K, Paliwal V. Unusual features in chronic inflammatory demyelinating polyneuropathy: Good outcome after prolonged ventilatory support. J Neurosci Rural Pract 2013; 2:171-3. [PMID: 21897683 PMCID: PMC3159356 DOI: 10.4103/0976-3147.83586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Severe respiratory muscle paralysis and ventilatory failure is rare in chronic inflammatory demyelinating polyneuropathy (CIDP). We report a 14 year child who presented with respiratory failure, bulbar and multiple cranial nerves involvement along with bilateral phrenic nerve paralysis. He was diagnosed with CIDP after electrophysiological evaluation. He required AMBU ventilation for about 4 months (including domiciliary use), after which he recovered significantly. Along with several unusual features of CIDP, this report highlights good example of steady basic intensive care to save lives and rewarding outcome of prolonged respiratory support, provided by AMBU ventilation which is a rather primitive, but inexpensive device.
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Affiliation(s)
- Sanjeev Jha
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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32
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Lambiris I, Mehta J, Helguera M. Shortness of breath after AV ablation: case of left phrenic nerve palsy. J Community Hosp Intern Med Perspect 2013; 3:19123. [PMID: 23882394 PMCID: PMC3716033 DOI: 10.3402/jchimp.v3i1.19123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/19/2012] [Accepted: 12/19/2012] [Indexed: 11/14/2022] Open
Abstract
Phrenic nerve palsy has been recognized as a complication of catheter ablation with a prevalence of 0.11-0.48% after atrial fibrillation ablation, independent of the type of ablation catheter or energy source, likely due to the anatomical relationship of the nerves. This report describes a case of new onset of shortness of breath (SOB) due to left diaphragm paralysis following transcatheter radiofrequency ablation in a patient with underlying chronic obstructive pulmonary disease.
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Affiliation(s)
- Irene Lambiris
- Department of Cardiology/Electophysiology, Pulmonary Critical Care and Internal Medicine, Cleveland Clinic, Weston, FL, USA
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Abstract
Birth injury is defined as an impairment of a newborn's body function or structure due to adverse influences that occurred at birth. Phrenic nerve palsy may result from birth trauma during a traumatic neonatal delivery from a stretch injury due to lateral hyperextension of the neck at birth. This could be a rare cause of respiratory distress in the newborn period with irregular respiration. Respiratory distress due to phrenic nerve damage leading to paralysis of the ipsilateral diaphragm may require continuous positive airway pressure or mechanical ventilation and if unresponsive, surgical plication of diaphragm. Herein, we report a case of phrenic nerve palsy in a newborn presenting with respiratory distress.
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Affiliation(s)
- V S S Yerramilli Murty
- Department of Pediatrics, Maharajhas Institute of Medical Sciences, Vizianagaram District, Andhra Pradesh, India
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34
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Schmidt B, Chun KRJ, Kuck KH, Antz M. Pulmonary vein isolation by high intensity focused ultrasound. Indian Pacing Electrophysiol J 2007; 7:126-33. [PMID: 17538703 PMCID: PMC1877830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pulmonary vein isolation (PVI) using radiofrequency current (RFC) ablation is a potentially curative treatment option for patients with atrial fibrillation (AF). The shortcomings of the RFC technology (technically challenging, long procedure times, complications) steadily kindle the interest in new energy sources and catheter designs. High intensity focused ultrasound (HIFU) has the ability to precisely focus ultrasound waves in a defined area with a high energy density. HIFU balloon catheters (BC) positioned at the PV ostia appear to be an ideal tool to transmit the ablation energy in a circumferential manner to the PV ostia and may therefore bear substantial advantage over conventional ablation catheters in PVI procedures. In clinical trials the HIFU BC has shown promising success rates similar to RFC catheter ablation for PVI in patients with AF. However, procedure times are still long and serious complications have been observed. Therefore, it may be a valuable alternative to the conventional techniques in selected patients but further clinical trials have to be initiated.
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Affiliation(s)
- Boris Schmidt
- Asklepios Klinik St. Georg, Department of Cardiology, Lohmuhlenstr. 5, 22099 Hamburg, Germany
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