The present study investigated both the clinical significance of atrial fibrillation (AF) before right atrial appendage (RAA) pacing and the influence of prolonged P wave on AF occurrence in RAA-paced patients with sick sinus syndrome (SSS). Fifty-seven patients (age 68+/-10 years; 19 men, 38 women) with SSS who underwent RAA pacing were divided into 2 groups: 23 patients without AF before pacing (I + II; Rubenstein I or II) and 34 patients with AF before pacing (III; Rubenstein III). The P wave duration in intrinsic rhythm and with RAA pacing were measured on the standard electrocardiography in leads II and V(1) with the use of a digitizing tablet. Group III was further subdivided into 2 groups: 20 patients (IIIb) with a paced P wave >130 ms in both leads II and V(1) and the other 14 patients (IIIa). The duration of the intrinsic P wave in leads II and V(1) was significantly greater in group III than in group I + II (119+/-20 vs 108+/-21 ms, p=0.0417, 106+/-16 vs 95+/-21 ms, p=0.0258, respectively). During the follow-up of 40+/-21 months, AF recurrence was significantly higher in group IIIb than in groups IIIa and I + II (17/20 vs 5/14 vs 2/23 p<0.0001). A few occurrences of AF were observed by conventional RAA pacing in patients without AF before pacing. However, SSS with AF before pacing caused a significant intra-atrial conduction disturbance and a high incidence of AF recurrence after implantation of RAA pacing, especially in patients with a prolonged paced P wave, in whom new pacing modalities may be needed to shorten paced P wave duration and prevent AF.