Inducibility of atrial fibrillation in the absence of atrial fibrillation: what does it mean to be normal?

Background: While inducibility of atrial fibrillation (AF) is often used as an endpoint for radiofrequency ablation of AF, little is known regarding inducibility among normals. We therefore evaluated the inducibility of AF with rapid atrial pacing in patients without a clinical history of AF after catheter ablation of supraventricular tachycardia (SVT).

Methods: We prospectively evaluated 86 patients with no history of AF who were referred for catheter ablation of SVT. After successful ablation, two different rapid atrial pacing protocols for induction of AF were tested. First, AF induction was attempted by 5-second bursts of atrial pacing from the coronary sinus ostium (CSO) at three different cycle lengths (CLs). Next, decremental pacing was performed from the CSO starting at a CL of 250 ms to the loss of 1:1 atrial capture. This protocol was repeated 3 times for each subject.

Results: Three of the subjects (3.5%) enrolled had inducible AF with the first pacing protocol. However, with the second protocol, AF was inducible in 22 patients (25.6%), including sustained AF in 16 patients (18.6%). There were significant differences in the inducibility of AF between the two atrial pacing protocols. Additionally, with the second pacing protocol, patients with a loss of 1:1 atrial capture at CL <180 ms were more easily inducible for AF (21/63 vs. 1/23; P = .006).

Conclusion: Using a specific, decremental pacing protocol, 26% of patients without a history of AF had inducible AF. These findings suggest that significant further investigation is needed to optimize the specificity of using AF induction as an endpoint for AF ablation.