A Case Report of Right Phrenic Nerve Palsy Following Pulsed Field Ablation in a Patient with Persistent Atrial Fibrillation.

Pulsed field ablation (PFA) is a nonthermal ablation modality that achieves myocardial ablation through irreversible electroporation and has been associated with a reduced risk of collateral tissue injury. Phrenic nerve injury is uncommon with PFA, and persistent injury has rarely been described. A 61-year-old woman with symptomatic persistent atrial fibrillation refractory to anti-arrhythmic drug therapy underwent catheter ablation using the PulseSelect™ PFA system (Medtronic, Minneapolis, MN, USA). Circumferential PFA applications were delivered to all four pulmonary veins, followed by additional applications to the posterior left atrial wall to achieve posterior wall isolation. A total of 61 pulsed field energy applications were delivered, and the entrance and exit blocks of the pulmonary veins and posterior wall were confirmed. The procedure was otherwise uncomplicated. Several hours post-procedure, the patient developed new-onset dyspnea. Chest radiography demonstrated elevation of the right hemidiaphragm consistent with right phrenic nerve palsy. Conservative management was initiated, with gradual symptomatic improvement. However, follow-up imaging at 3 months demonstrated persistent right hemidiaphragmatic elevation. This case demonstrates that phrenic nerve palsy may occur following pulmonary vein and posterior wall isolation using PFA. Continued awareness of this potential complication and careful post-procedural follow-up are warranted as clinical experience with PFA continues to expand.