Is there an optimal pacing site to prevent atrial fibrillation?: An experimental study in the chronically instrumented goat

Preventive Atrial Pacing in AF. Introduction: Atrial pacing can reduce the number of recurrences of atrial fibrillation (AF). It is unclear the extent to which this effect is determined by the site(s) of pacing. Methods and Results: In six electrically remodeled goats (24-hour AF), the window of inducibility of AF was determined by applying premature stimuli (S1-S2) at the right (RA) or left (LA) atrium (baseline values). Determination of the window of inducibility of AF at RA and LA was repeated during preventive pacing at four sites: RA, LA, Bachmann's bundle (BB), and RA+LA (biatrial). Mapping was used to elucidate the mechanisms of prevention of AF. At baseline, the window of inducibility of AF was 49 +/- 9 msec at RA and 45 +/- 17 msec at LA. Initiation of AF was associated with conduction block of the premature beat at BB. Preventive pacing at BB markedly shortened the window of inducibility of AF at RA (25 +/- 11 msec) and LA (17 +/- 8 msec, P < 0.01). Pacing at RA only shortened the window of inducibility of AF at LA (23 +/- 9 msec, P < 0.01), whereas pacing at LA only shortened the window of inducibility of AF at RA (23 +/- 11 msec, P < 0.01). Biatrial pacing failed to shorten the window of inducibility of AF both at RA and LA. Prevention of AF by pacing was due to prolongation of the premature interval at BB. Conclusion: In the caprine model of AF, BB is a critical area of conduction of premature beats and initiation of AF. Pacing at BB can prevent but not completely abolish the initiation of AF by single premature beats (shortening of the window of inducibility). Prevention of AF by pacing is based on prolongation of the premature interval at BB, thus preventing conduction block and reentry. In general, the optimal site for preventive pacing is close to the area of block and remote from the origin of premature beats.