Fig. 2

Isolation of the RSPV using CB3 with the “push-up” maneuver. A shorter-tip third-generation cryoballoon (CB 3, Arctic Front Advance Pro., Medtronic) was selected for PVI. The transseptal sheath was exchanged over a guidewire for a 12-Fr steerable sheath (Flexcath Advance, Medtronic). The 28-mm CB 3 was advanced into the LA via the 12-Fr steerable sheath under the guidance of spiral mapping catheter (Achieve, 20 mm, Medtronic). A temperature probe (Sensitherm, St. Jude Medical) was advanced into the esophagus to monitor esophageal temperatures during freeze. During freeze the right PVs, phrenic nerve (PN) function was monitored by continuous PN pacing using a diagnostic catheter positioned at the superior vena cava (7-Fr, ParaHis, Biosense Webster). Pacing was set at maximum output and pulse width (12 mA, 2.9 ms) and a cycle length of 1200 ms. PN pacing-generated “Compound motor action potential” (CMAP) was continuously monitored during freeze. a First angiography showed contrast leak at the roof of RSPV. b After a push-up maneuver, the second angiography showed that the RSPV was perfectly occluded and real-time isolated within 50 s, minimal temperature was − 56 °C, freeze duration was set at 240 s, without evidence of PN palsy and PV perforation. c Electrogram showed the moment of RSPV isolation and continuous CMAP monitoring for PN function