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Volume 13, Issue 1, Pages 28-36 (January 2016) Effect of cryoballoon inflation at the right superior pulmonary vein orifice on phrenic nerve location Kazuki Iso, MD, Koichi Nagashima, MD, PhD, Yasuo Okumura, MD, PhD, Ichiro Watanabe, MD, PhD, FHRS, Toshiko Nakai, MD, PhD, Kimie Ohkubo, MD, PhD, Kazumasa Sonoda, MD, Rikitake Kogawa, MD, Naoko Sasaki, MD, Keiko Takahashi, MD, Sayaka Kurokawa, MD, PhD, Mizuki Nikaido, BE, Atsushi Hirayama, MD, PhD Heart Rhythm Volume 13, Issue 1, Pages 28-36 (January 2016) DOI: 10.1016/j.hrthm.2015.08.013 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Schematic diagram of measurements before (A) and after (B) cryoballoon inflation. The left atrium (LA)/right superior pulmonary vein (RSPV) and virtual delineated phrenic nerve (PN; blue tags) are indicated. The following measurements were obtained: (1) PN capture area/points in the RSPV (pink tags before inflation, and green tags after inflation); (2) the shortest distance between the PN capture point closest to the RSPV orifice and the delineated PN location; (3) the shortest distance between the PN capture point closest to the RSPV orifice and the RSPV orifice; and (4) the distance between the anterior surface of RSPV orifice and that of interpolated RSPV orifice after balloon inflation. Heart Rhythm 2016 13, 28-36DOI: (10.1016/j.hrthm.2015.08.013) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 Representative fluoroscopic images of phrenic mapping by pacing from the right superior pulmonary vein (RSPV) orifice and left atrium (LA) after balloon inflation. Details are given in the text. CS = coronary sinus; SVC = superior vena cava. Heart Rhythm 2016 13, 28-36DOI: (10.1016/j.hrthm.2015.08.013) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Representative images in the right lateral (A, C) and right anterior oblique (B, D) views of LA/PV geometry, PN location, and PN capture points before and after cryoballoon inflation in a patient without PN injury. The PN capture points by pacing from RA to SVC (delineated PN location) are indicated by blue tags and PN capture points from the RSPV by pink tags. Before cryoballoon inflation, the area of PN capture points within the RSPV is 0.7 cm2 (5 points), the shortest distance between the PN capture point closest to the RSPV orifice is 17 mm (A), and the shortest distance between the PN capture point closest to the RSPV orifice and the RSPV orifice is 12 mm (B). Cryoballoon inflation caused the interpolated surface of the RSPV orifice to move anteriorly by 6 mm, resulting in balloon inflation predominantly widening the PN capture area by 1.5 cm2 and shortening the distances between the PN capture point vs PN location by 12 mm (C) and PN capture point vs RSPV orifice by 7 mm (D). LA = left atrium; PN = phrenic nerve; PV = pulmonary vein; RA = right atrium; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein; SVC = superior vena cava. Heart Rhythm 2016 13, 28-36DOI: (10.1016/j.hrthm.2015.08.013) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 4 Representative images in the right lateral (A) and right anterior oblique (B) views of LA/PV geometry, PN location, and PN capture points before and after cryoballoon inflation in a patient who had transient PN injury during cryothermal application. The PN capture area is widened (from 2.8 to 3.4 cm2), and the distances between the PN capture sites closest to the RSPV and the PN location (from 16 to 4 mm) and to the RSPV orifice before inflation (from 6 to 0 mm) are predominantly shortened after balloon inflation. Note that the PN capture points are located adjacent to the RSPV orifice line after balloon inflation. The bipolar voltage map of the PV/LA after cryothermal application is shown in B, with the purple area indicating a voltage area >0.5 mV. Areas colored red, orange, yellow, green, or blue are low-voltage areas of 0.05–0.5 mV. A low-voltage area is observed around the RSPV orifice line, suggesting that the PN capture points closest to the RSPV orifice are adjacent to the estimated freezing sites created by the balloon surface contact. Details of the measurements and abbreviations as in Figure 3. Heart Rhythm 2016 13, 28-36DOI: (10.1016/j.hrthm.2015.08.013) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 5 Graphs showing the change in individual measurements before and after cryoballoon inflation. A: Phrenic nerve (PN) capture area. B: PN capture points. C: Distance of the PN capture point closest to the right superior pulmonary vein (RSPV) vs delineated PN location. D: Distance of the PN capture point closest to the RSPV orifice vs the RSPV orifice. *P <.05 for phrenic nerve injury (PNI) group vs non-PNI group. Heart Rhythm 2016 13, 28-36DOI: (10.1016/j.hrthm.2015.08.013) Copyright © 2016 Heart Rhythm Society Terms and Conditions