Pain perception during esophageal warming due to radiofrequency catheter ablation in the left atrium

  • Marco GaleazziEmail author
  • Sabina Ficili
  • Serena Dottori
  • Mohamed Abdelkader Elian
  • Vincenzo Pasceri
  • Franco Venditti
  • Maurizio Russo
  • Carlo Lavalle
  • Angela Pandozi
  • Claudio Pandozi
  • Massimo Santini



We investigated the relationship among esophageal warming, pain perception, and the site of radiofrequency (RF) delivery in the left atrium (LA) during the course of catheter ablation of atrial fibrillation. Such a procedure in awake patients is often linked to the development of visceral pain and esophageal warming. As a consequence, potentially dangerous complications have been described.


Twenty patients undergoing RF ablation in the LA were studied. An esophageal probe (EP) capable of measuring endoesophageal temperature (ET) was positioned before starting the procedure. The relative position of the EP and the tip of the ablator were evaluated through fluoroscopy imaging before starting each RF delivery, during which the highest value of the temperature was collected. After RF withdrawal, the patients were asked to define the intensity of the experienced pain by using a score index ranging from 0 (no pain) to 4 (pain requiring immediate RF interruption).


The mean ET value during ablation was 39.59 ± 4.71°C. The EP proximity to the ablator’s tip showed a high correlation with the development of the highest ET values (Spearman’s rank correlation coefficient r = 0.49, confidence interval (CI) 0.55–0.41). Moreover, the highest values of pain intensity were reported when the RF was delivered to the atrial zones close to the EP projection (r = 0.50, CI 0.55–0.42) and when the highest ET levels were reached (r = 0.38, CI 0.30–0.45).


Pain perception in LA ablation is significantly related to esophageal warming and is higher when the RF is delivered near the esophagus. It seems advisable to perform ET monitoring in sedated patients to avoid short- and long-term jeopardizing of the esophageal wall.


Atrial fibrillation Catheter ablation Esophageal temperature Esophageal injury Pain 



Left atrium




Esophageal probe


Esophageal temperature



We are indebted to the personal contribution of professor Robert T. Jantzen Ph.D., Department of Mathematical Sciences, Villanova University, PA, USA, for his precious help in revising the manuscript. We are similarly indebted to the expertise of our EP rooms’ nursing staff (Carlo Iacoangeli, Luigi Muredda, Tiziana Zuccari, Luca Montacci, Mirella Volpe, Roberta Traditi, and Luigia Bartoccini) that made this study possible.


  1. 1.
    Pappone, C., Oral, H., Santinelli, V., Vicedomini, G., Lang, C. C., Manguso, F., et al. (2004). Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation, 109, 2724–2726.CrossRefPubMedGoogle Scholar
  2. 2.
    Dagres, N., Kottkamp, H., Piorkowski, C., Doll, N., Mohr, F., Horlitz, M., et al. (2006). Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: Lessons from five cases. Journal of Cardiovascular Electrophysiology, 17(11), 1213–1215.CrossRefPubMedGoogle Scholar
  3. 3.
    Ghia, K. K., Chugh, A., Good, E., Pelosi, F., Jongnarangsin, K., Bogun, F., et al. (2009). A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. Journal of Interventional Cardiac Electrophysiology, 24(1), 33–36.CrossRefPubMedGoogle Scholar
  4. 4.
    Hornero, F., & Berjano, E. J. (2006). Esophageal temperature during radiofrequency-catheter ablation of left atrium: A three-dimensional computer modeling study. Journal of Cardiovascular Electrophysiology, 17(4), 405–410.CrossRefPubMedGoogle Scholar
  5. 5.
    Cummings, J. E., Schweikert, R. A., Saliba, W. I., Burkhardt, J. D., Brachmann, J., Gunther, J., et al. (2005). Assessment of temperature, proximity, and course of the esophagus during radiofrequency ablation within the left atrium. Circulation, 112, 459–464.CrossRefPubMedGoogle Scholar
  6. 6.
    Aryana, A., Heist, E. K., D'Avila, A., Holmvang, G., Chevalier, J., Ruskin, J. N., et al. (2008). Pain and anatomical locations of radiofrequency ablation as predictors of esophageal temperature rise during pulmonary vein isolation. Journal of Cardiovascular Electrophysiology, 19(1), 32–38.PubMedGoogle Scholar
  7. 7.
    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 veins. Pacing and Clinical Electrophysiology, 30(10), 1210–1214.CrossRefPubMedGoogle Scholar
  8. 8.
    Kuwahara, T., Takahashi, A., Kobori, A., Miyazaki, S., Takahashi, Y., Takei, A., et al. (2009). Safe and effective ablation of atrial fibrillation: importance of esophageal temperature monitoring to avoid periesophageal nerve injury as a complication of pulmonary vein isolation. Journal of Cardiovascular Electrophysiology, 20(1), 1–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Sra, J., Krum, D., Malloy, A., Bhatia, A., Cooley, R., Blanck, Z., et al. (2006). Posterior left atrial–esophageal relationship throughout the cardiac cycle. Journal of Interventional Cardiac Electrophysiology, 16(2), 73–80.CrossRefPubMedGoogle Scholar
  10. 10.
    Good, E., Oral, H., Lemola, K., Han, J., Tamirisa, K., Igic, P., et al. (2005). Movement of the esophagus during left atrial catheter ablation for atrial fibrillation. Journal of the American College of Cardiology, 46(11), 2107–2110.CrossRefPubMedGoogle Scholar
  11. 11.
    Kennedy, R., Good, E., Oral, H., Huether, E., Bogun, F., Pelosi, F., et al. (2008). Temporal stability of the location of the esophagus in patients undergoing a repeat left atrial ablation procedure for atrial fibrillation or flutter. Journal of Cardiovascular Electrophysiology, 19(4), 351–355.CrossRefPubMedGoogle Scholar
  12. 12.
    Krishnan, S. C., Salazar, M., & Narula, N. (2008). Anatomical basis for the mobility of the esophagus: implications for catheter ablation of atrial fibrillation. Indian Pacing Electrophysiology Journal, 8(1), 66–68.Google Scholar
  13. 13.
    Huskisson, E. C. (1974). Measurement of pain. Lancet, 2, 1127–1131.CrossRefPubMedGoogle Scholar
  14. 14.
    Wiesenfeld-Hallin, Z. (2005). Sex differences in pain perception. Gender Medicine, 2(3), 137–145.CrossRefPubMedGoogle Scholar
  15. 15.
    Arendt-Nielsen, L., Bajaj, P., & Drewes, A. M. (2004). Visceral pain: gender differences in response to experimental and clinical pain. European Journal of Pain, 8(5), 465–472.CrossRefPubMedGoogle Scholar
  16. 16.
    Chesterton, L. S., Barlas, P., Foster, N. E., Baxter, G. D., & Wright, C. C. (2003). Gender differences in pressure pain threshold in healthy humans. Pain, 101(3), 259–266.CrossRefPubMedGoogle Scholar
  17. 17.
    Sun, L. S. (1998). Gender differences in pain sensitivity and responses to analgesia. Journal of Gender Specific Medicine, 1(1), 28–30.PubMedGoogle Scholar
  18. 18.
    Cummings, J. E., Barrett, C. D., Litwak, K. N., DI Biase, L., Chowdhury, P., Oh, S., et al. (2008). Esophageal luminal temperature measurement underestimates esophageal tissue temperature during radiofrequency ablation within the canine left atrium: comparison between 8 mm tip and open irrigation catheters. Journal of Cardiovascular Electrophysiology, 19(6), 641–644.CrossRefPubMedGoogle Scholar
  19. 19.
    Aupperle, H., Doll, N., Walther, T., Kornherr, P., Ullmann, C., Schoon, H. A., et al. (2005). Ablation of atrial fibrillation and esophageal injury: Effects of energy source and ablation technique. Journal of Thoracic and Cardiovascular Surgery, 130(6), 1549–1554.CrossRefPubMedGoogle Scholar
  20. 20.
    Doll, N., Aupperle, H., Borger, M., Czesla, M., & Mohr, F. W. (2007). Efficacy and safety of various energy sources and application techniques for the surgical treatment of atrial fibrillation. Herzschrittmachertherapie & Elektrophysiologie, 18(2), 83–91. [Article in German].CrossRefGoogle Scholar
  21. 21.
    Evonich, R. F., 3rd, Nori, D. M., & Haines, D. E. (2007). A randomized trial comparing effects of radiofrequency and cryoablation on the structural integrity of esophageal tissue. Journal of Interventional Cardiac Electrophysiology, 19(2), 77–83.CrossRefPubMedGoogle Scholar
  22. 22.
    Ripley, K. L., Gage, A. A., Olsen, D. B., Van Vleet, J. F., Lau, C. P., & Tse, H. F. (2007). Time course of esophageal lesions after catheter ablation with cryothermal and radiofrequency ablation: Implication for atrio-esophageal fistula formation after catheter ablation for atrial fibrillation. Journal of Cardiovascular Electrophysiology, 18(6), 642–646.CrossRefPubMedGoogle Scholar
  23. 23.
    Schmidt, M., Nölker, G., Marschang, H., Gutleben, K. J., Schibgilla, V., Rittger, H., et al. (2008). Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation. Europace, 10(2), 205–209.CrossRefPubMedGoogle Scholar
  24. 24.
    Singh, S. M., d’Avila, A., Doshi, S. K., Brugge, W. R., Bedford, R. A., Mela, T., et al. (2008). Esophageal injury and temperature monitoring during atrial fibrillation. Circulation Arrhythmia Electrophysiology, 1, 162–168.CrossRefGoogle Scholar
  25. 25.
    Tsuchiya, T., Ashikaga, K., Nakagawa, S., Hayashida, K., & Kugimiya, H. (2007). Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study. Journal of Cardiovascular Electrophysiology, 18(2), 145–150.CrossRefPubMedGoogle Scholar
  26. 26.
    Berjano, E. J., & Hornero, F. (2005). A cooled intraesophageal balloon to prevent thermal injury during endocardial surgical radiofrequency ablation of the left atrium: A finite element study. Physics in Medicine and Biology, 50(20), N269–N279.CrossRefPubMedGoogle Scholar
  27. 27.
    Lequerica, J. L., Berjano, E. J., Herrero, M., Melecio, L., & Hornero, F. (2008). A cooled water-irrigated intraesophageal balloon to prevent thermal injury during cardiac ablation: experimental study based on an agar phantom. Physics in Medicine and Biology, 53(4), N25–N34.CrossRefPubMedGoogle Scholar
  28. 28.
    Arruda MS, Armaganijan L, di Biase L, Rashidi R, Natale A. (2009). Feasibility and safety of using an esophageal protective system to eliminate esophageal thermal injury: Implications on atrial–esophageal fistula following AF ablation. Journal of Cardiovascular Electrophysiology.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Marco Galeazzi
    • 1
    Email author
  • Sabina Ficili
    • 1
  • Serena Dottori
    • 1
  • Mohamed Abdelkader Elian
    • 2
  • Vincenzo Pasceri
    • 1
  • Franco Venditti
    • 3
  • Maurizio Russo
    • 1
  • Carlo Lavalle
    • 1
  • Angela Pandozi
    • 1
  • Claudio Pandozi
    • 1
  • Massimo Santini
    • 1
  1. 1.Dipartimento CardiovascolareOspedale San Filippo NeriRomeItaly
  2. 2.Department of CardiologyBenha University HospitalBenhaEgypt
  3. 3.Dipartimento CardiovascolarePoliclinico Militare Celio “Attilio Friggeri”RomeItaly

Personalised recommendations