Background Delayed afterdepolarizations (DADs) carried by Na+-Ca2+-exchange current (INCX) in response to sarcoplasmic reticulum (SR) Ca2+-leak can promote atrial fibrillation (AF). The mechanisms leading to DADs in AF-patients have not been defined. Methods and Results Protein levels (Western-blot), membrane-currents and action-potentials (patch-clamp), and [Ca2+]i (Fluo-3) were measured in right-atrial samples from 77 sinus-rhythm (Ctl) and 69 chronic-AF (cAF) patients. Diastolic [Ca2+]i and SR-Ca2+-content (integrated INCX during caffeine-induced-Ca2+-transient [cCaT]) were unchanged, whereas diastolic SR Ca2+-leak, estimated by blocking RyR2 with tetracaine, was ~50% higher in cAF vs. Ctl. Single-channel recordings from atrial RyR2 reconstituted into lipid-bilayers revealed enhanced open-probability in cAF-samples, providing a molecular basis for increased SR Ca2+-leak. Calmodulin-expression (+60%), CaMKII-autophosphorylation at Thr287 (+40%) and RyR2-phosphorylation at Ser2808 (PKA/CaMKII-site, +236%) and Ser2814 (CaMKII-site, +77%) were increased in cAF. The selective CaMKII-blocker KN-93 decreased SR Ca2+-leak, the frequency of spontaneous Ca2+-release events and RyR2 open-probability in cAF, whereas PKA-inhibition with H-89 was ineffective. Knock-in mice with constitutively-phosphorylated RyR2 at Ser2814 showed a higher incidence of Ca2+-sparks and increased susceptibility to pacing-induced AF vs. controls. The relationship between [Ca2+]i and INCX-density revealed INCX-upregulation in cAF. Spontaneous Ca2+-release events accompanied by inward INCX-currents and DADs/triggered-activity occurred more often and the sensitivity of resting membrane voltage to elevated [Ca2+]i (diastolic [Ca2+]i–voltage coupling gain) was higher in cAF vs. Ctl. Conclusions Enhanced SR Ca2+-leak through CaMKII-hyperphosphorylated RyR2, in combination with larger INCX for a given SR Ca2+-release and increased diastolic [Ca2+]i–voltage coupling gain, cause AF-promoting atrial DADs/triggered-activity in cAF patients.

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