Inducibility of Atrial Fibrillation with a Synchronized External Low Energy Shock Post-Pulmonary Vein Isolation Predicts Recurrent Atrial Fibrillation

Background: Inducibility of atrial fibrillation (AF) with burst pacing after pulmonary vein (PV) isolation is associated with recurrent AF. Objective: This study evaluated whether an external 30 Joule (J) shock synchronized to the R wave, during the vulnerable period of atrial repolarization, is able to risk‐stratify patients further for AF recurrence after PV isolation. Methods: One hundred and sixteen consecutive patients underwent PV isolation for AF. Atrial burst pacing was performed after PV isolation. In patients without AF induced by burst pacing, a biphasic external 30 J shock synchronized to the R wave was delivered as a further test for inducible AF. Patients were followed for a mean of 16 months, and recurrent AF was defined as more than 10 sec of AF on ambulatory monitoring. Results: AF was induced in 19 (16%) of patients with burst pacing. Eighty‐one patients who were noninducible with burst pacing had a 30 J shock administered, which induced AF in 16 (20%). In follow‐up, 21% of patients who were noninducible with burst pacing or low‐energy shock vs 54% who were inducible with either test developed recurrent AF at one year (HR 3.18, P = 0.0004 on multivariate analysis). Among patients who were noninducible with burst pacing, 18% who were noninducible with a low‐energy shock vs 60% who were inducible with shock developed recurrent AF at one year (HR = 4.63, P = 0.0006 on multivariate analysis). Conclusion: Inducibility of AF by a 30 J shock delivered during atrial repolarization after PV isolation may predict AF recurrence. Evaluation of inducibility of AF with burst pacing and a biphasic external synchronized shock after PV isolation may help guide postprocedure management.