Site localization of painful lesions during radiofrequency ablation of pulmonary veins using circular multi-electrode catheters

  • Avishag Laish-Farkash
  • Amos Katz
  • Ornit Cohen
  • Azriel Osherov
  • Sharon Bruocha
  • Vladimir Khalameizer



Previous data showed that pain sensation was common during pulmonary vein isolation (PVI) using an 8-mm radiofrequency (RF) ablation catheter. Pain was more common in the left pulmonary veins (PVs). We characterized the location of pain during PVI using circular multi-electrode ablation catheters.


Included are all consecutive patients with atrial fibrillation (AF) who underwent PVI using the phased RF PVAC® catheter (Medtronic) or the irrigated nMARQ™ catheter (Biosense Webster) under conscious sedation between July 2011 and March 2015. Site of pain reaction was marked for each patient.


A total of 251 patients (141 PVAC®, 110 nMARQ™) were studied; 214 (85 %) had at least one lesion associated with pain. Gender (r = 0.084, p = 0.186), type of AF (r = 0.048, p = 0.452), age (r = 0.078, p = 0.216), and repeat procedure (r = 0.018, p = 0.78) were not correlated with pain. There was no association between site of pain and catheter type; only 33 % of the painful PVs were also the largest ones (p = 0.5, kappa = 0.03, R = −0.083). One-year freedom from AF was similar for patients with and without painful PVs (p = 0.6). The distribution of pain was as follows: 126 (59 %) left superior PV (LSPV), 28 (13 %) left inferior, 28 (13 %) all PVs, 12 (5.6 %) right superior, 12 (5.6 %) right inferior, 18 (8.4 %) left common, and 2 (0.9 %) right common PV.


PVI using multi-electrode catheters more commonly caused pain sensation in LSPV. There was no influence of catheter type or PV size on pain localization. Our findings, which are similar to those using an 8-mm ablation catheter, imply that location of pain is not catheter dependent but rather a reflection of autonomic physiology.


Atrial fibrillation Ablation Circular multi-electrode catheter Pain Pulmonary veins 



No financial support was received for this study.

Compliance with ethical standards

The study protocol was approved by our institution review board and was not influenced by Medtronic or Biosense Webster companies.

Informed consent

All patients provided an informed consent prior to the procedure.


  1. 1.
    Carnlöf, C., Insulander, P., & Jensen-Urstad, M. (2014). An active supply of analgesics during pulmonary vein isolation reduces pain. Scandinavian Cardiovascular Journal, 48(1), 35–40.CrossRefPubMedGoogle Scholar
  2. 2.
    Di Biase, L., Conti, S., Mohanty, P., Bai, R., Sanchez, J., Walton, D., et al. (2011). General anesthesia reduces the prevalence of pulmonary vein reconnection during repeat ablation when compared with conscious sedation: results from a randomized study. Heart Rhythm, 8(3), 368–372.CrossRefPubMedGoogle Scholar
  3. 3.
    Cho, J. S., Shim, J. K., Na, S., Park, I., & Kwak, Y. L. (2014). Improved sedation with dexmedetomidine-remifentanil compared with midazolam-remifentanil during catheter ablation of atrial fibrillation: a randomized controlled trial. Europace, 16(7), 1000–1006.CrossRefPubMedGoogle Scholar
  4. 4.
    Timmermans, C., Ayers, G. M., Crijns, H. J., & Rodriguez, L. M. (2003). Randomized study comparing radiofrequency ablation with cryoablation for the treatment of atrial flutter with emphasis on pain perception. Circulation, 107, 1250–1252.CrossRefPubMedGoogle Scholar
  5. 5.
    Alaeddini, J., Wood, M. A., Parvez, B., Pathak, V., Wong, K. A., & Ellenbogen, K. A. (2007). Site localization and characterization of pain during radiofrequency ablation of the pulmonary vein. PACE, 30, 1210–1214.CrossRefPubMedGoogle Scholar
  6. 6.
    Defaye, P., Kane, A., Jacon, P., & Mondesert, B. (2010). Cryoballoon for pulmonary vein isolation: is it better tolerated than radiofrequency? Retrospective study comparing the use of analgesia and sedation in both ablation techniques. Archives of Cardiovascular Disease, 103, 388–393.CrossRefGoogle Scholar
  7. 7.
    Wieczorek, M., Hoeltgen, R., Bruek, M., Bandorski, D., Akin, E., & Salili, A. R. (2010). Pulmonary vein isolation by duty-cycled bipolar and unipolar antrum ablation using a novel multielectrode ablation catheter system: first clinical results. Journal of Interventional Cardiac Electrophysiology, 27, 23–31.CrossRefPubMedGoogle Scholar
  8. 8.
    Shin, D. I., Kirmanoglou, K., Eickholt, C., Schmidt, J., Clasen, L., Butzbach, B., et al. (2014). Initial results of using a novel irrigated multielectrode mapping and ablation catheter for pulmonary vein isolation. Heart Rhythm, 11(3), 375–383.CrossRefPubMedGoogle Scholar
  9. 9.
    Packer, D. L., Kowal, R. C., Wheelan, K. R., Irwin, J. M., Champagne, J., Guerra, P. G., et al. (2013). Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) Pivotal Trial. American College of Cardiology, 61(16), 1713–1723.CrossRefGoogle Scholar
  10. 10.
    Verma, A., Debruyne, P., Nardi, S., Deneke, T., DeGreef, Y., Spitzer, S., ERACE investigators, et al. (2013). ERACE trial. Circulation. Arrhythmia and Electrophysiology, 6(5), 835–842.CrossRefPubMedGoogle Scholar
  11. 11.
    Eitel, C., Hindricks, G., Sommer, P., Gaspar, T., Kircher, S., Wetzel, U., et al. (2010). Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace-and-ablate approach. Heart Rhythm, 7, 157–164.CrossRefPubMedGoogle Scholar
  12. 12.
    Armour, J. A., Murphy, D. A., Yuan, B. X., MacDonald, S., & Hopkins, D. A. (1997). Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anatomical Record, 247, 289–298.CrossRefPubMedGoogle Scholar
  13. 13.
    Armour, J. A. (2004). Cardiac neuronal hierarchy in health and disease. American Journal of Physiology. Regulatory, Integrative and Comparative Physiology, 287, R262–R271.CrossRefPubMedGoogle Scholar
  14. 14.
    Huang, M. H., Negoescu, R. M., Horackova, M., Wolf, S., & Armour, J. A. (1996). Polysensory response characteristics of dorsal root ganglion neurones that may serve sensory functions during myocardial ischemia. Cardiovascular Research, 32, 503–515.CrossRefPubMedGoogle Scholar
  15. 15.
    Thompson, G. W., Horackova, M., & Armour, J. A. (2002). Role of P1 purinergic receptors in myocardial ischemia sensory transduction. Cardiovascular Research, 53, 888–901.CrossRefPubMedGoogle Scholar
  16. 16.
    Armour, J. A., Huang, M. H., Pelleg, A., & Sylvén, C. (1994). Responsiveness of in situ canine nodose ganglion cardiac afferent neurons to epicardial mechanoreceptors and/or chemoreceptor stimuli. Cardiovascular Research, 28, 1218–1225.CrossRefPubMedGoogle Scholar
  17. 17.
    Herr, K. A., & Garand, L. (2001). Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine, 17, 457–458.PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Breivik, H., Borchgrevink, P. C., Allen, S. M., Rosseland, L. A., Romundstad, L., Hals, E. K., et al. (2008). Assessment of pain. British Journal of Anaesthesia, 101, 17–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Avishag Laish-Farkash
    • 1
    • 2
  • Amos Katz
    • 1
    • 2
  • Ornit Cohen
    • 1
    • 2
  • Azriel Osherov
    • 1
    • 2
  • Sharon Bruocha
    • 1
    • 2
  • Vladimir Khalameizer
    • 1
    • 2
  1. 1.Electrophysiology Unit, Cardiology DepartmentBarzilai Medical CenterAshkelonIsrael
  2. 2.Faculty of Health SciencesBen-Gurion University of the NegevBeer-ShevaIsrael

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