Recovery of retrograde fast pathway excitability in the atrioventricular node reentrant circuit after concealed anterograde impulse penetration

Department of Internal Medicine, Wayne State University/Harper Hospital, Detroit, Michigan.

The recovery of the retrograde fast pathway excitability in atrioventricular (AV) node reentry has been difficult to assess with ventricular extrastimulation because of difficulty in achieving sufficiently short intranodal coupling intervals and the potential interposition of "lower common pathway" nodal tissue. To circumvent these methodologic obstacles in 10 patients with inducible AV node reentrant tachycardia, a fixed atrial extrastimulus (A2) coupled to a basic atrial drive (A1) at a cycle length of 500 ms was utilized to reproducibly initiate AV node reentrant echoes. A ventricular extrastimulus (V3) was then introduced after A2 at progressively shorter coupling intervals (A2V3) in an attempt to pre-excite the retrograde fast pathway after concealed anterograde penetration by A2. In six patients, retrograde fast pathway pre-excitation was achieved at critical A2V3 intervals, as evidenced by the appearance of A3 by up to 28 +/- 6 ms in advance of the expected first AV node reentrant echo. In five of the six cases, the V3A3 interval was virtually unaltered (less than or equal to 5 ms decrease) when A2 was omitted. In seven patients, at a critically short A2V3 coupling interval (195 +/- 27 ms ), V3 abruptly failed to elicit A3 and concomitantly abolished all AV node echoes; yet when A2 was omitted, an A3 response returned, with V3A3 identical to previous values.(ABSTRACT TRUNCATED AT 250 WORDS)