How to Induce Arrhythmias by Atrial and Ventricular Programmed Stimulation

In recent decades, invasive electrophysiological study (ES) has become an important instrument to evaluate patients with conduction disturbance and cardiac arrhythmias. Using catheters placed in heart chambers via central vein and/or central arterial access, ES may evaluate sinus node function, atrioventricular conduction, and tachyarrhythmias. Cardiac arrhythmias may not always be present in the baseline condition. Therefore, it is necessary to induce these arrhythmias by programmed pacing protocols. Commonly arrhythmias are seen as chaotic alterations of the normal heart conduction and of the normal heart rhythm, and then they are defined as cardiac rhythm disorders. Cardiac arrhythmias present with a common phenotype, characterized by irregularity of the cardiac rhythm and related clinical symptoms. In this setting, ES may be performed by using different diagnostic and pacing catheters and pacing protocols. Programmed pacing protocols involve incremental pacing, coupled with the introduction of single or multiple premature stimuli during one or more drive cycles. The pacing protocols are performed with a current output of twice the diastolic threshold or more, and at one or more sites. Therefore, a great discrepancy may exist between arrhythmia induction techniques in different laboratories. However, in the majority of cases, arrhythmias are due to specific arrhythmic electrical, anatomical, and/or electroanatomical circuits. These circuits respond to specific conduction properties of the systolic and diastolic electrical phases, which are reproducible and evocable by external triggers and by specific pacing techniques. Moreover, in the light of these observations, we have to stress the concept that induction and stimulation programs have to be selected and then paced to test the arrhythmic circuits for refractoriness and to trigger the conduction properties of the arrhythmic pathways. Therefore, we have to make arrhythmia induction protocols more uniform and as standardized as possible to avoid all possible bias. Indeed, how to induce arrhythmias by atrial and ventricular stimulation remains a relevant question that needs a specific and unique response. To respond to this question, we would like to introduce the concept that a pacing protocol to induce cardiac arrhythmias may be standard and programmed. As first, by programmed pacing, physicians may study the properties of the cardiac conduction system. This may be secondarily achieved by introduction of early stimuli to determine the conduction response, as a specific arrhythmia induction protocol. As discussed earlier, the type of induction and the chosen programmed stimulation protocol may be selected with regard to the type of arrhythmia the patient is suspected to have. In fact, re-entry tachycardias may usually be triggered using extrastimuli to stimulate the conduction pathways in slow conduction and fast conduction ways. Differently, automatic tachycardias not due to re-entry mechanisms may be more easily induced by burst pacing. In this chapter we would like to introduce pacing protocols to induce cardiac arrhythmias. Apart from the similarity of the diagnostic and pacing catheters, and in the setting of programmed stimulation protocols, the differences in the paced heart chambers and in the induced tachycardias teach us to separate the discussion of atrial stimulation from ventricular stimulation protocols. Therefore, we schematically divide the arrhythmia induction protocols into two separate chapter sections, discussing atrial stimulation protocols and ventricular stimulation protocols.