Rate-related accelerating (autodecremental) atrial pacing for reversion of paroxysmal supraventricular tachycardia.

Twenty consecutive patients with paroxysmal intra A-V nodal or atrio-ventricular tachycardia had a new tachycardia reversion pacing modality evaluated during routine electrophysiological study. The pacing was controlled by a micropressor interfaced with a stimulator connected to a right atrial pacing electrode. On detection of tachycardia the first pacing cycle interval is equal to the tachycardia cycle length minus a decrement value D. Each subsequent pacing cycle is further reduced by the same value of D, thus accelerating the pacing burst until a plateau of 100 beats/min faster than tachycardia (with an absolute lower limit of 275 beats/min) is reached. Seven different values of D (2, 4, 8, 16, 24, 34, 50 msec) were assessed in combination with three different durations of pacing P (500, 5000 msec). With P:500, only 2/20 tachycardias were terminated, but with P:1000, 16/20 were terminated. With P:5000 all were terminated and the combination successful in all patients was P:5000 and D:16. No unwanted arrhythmias were induced. In contrast, competitive constant rate overdrive atrial pacing accomplished tachycardia termination in all cases, but in four instances resulted in atrial flutter or fibrillation. Autodecremental pacing, which tends to avoid stimulation in the vulnerable period, allowed safe and successful termination of all tachycardias evaluated in this study.