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CLINICAL STUDIES

Heterogeneity of anterograde fast-pathway and retrograde slow-pathway conduction patterns in patients with the fast–slow form of atrioventricular nodal reentrant tachycardia: electrophysiologic and electrocardiographic considerations

Hiroko Nawata, MD^a, Naohito Yamamoto, MD^a, Kenzo Hirao, MD^a, Nobuyuki Miyasaka, MD^a, Tokuhiro Kawara, MD^*, Kazumasa Hiejima, MD^*, Tomoo Harada, MD and Fumio Suzuki, MD, FACC^a

^a The First Department of Internal Medicine, Tokyo Medical and Dental University, Tokyo, Japan
^* School of Allied Health Sciences, Tokyo Medical and Dental University, Tokyo, Japan
St. Marianna University Toyoko Hospital, Kawasaki, Japan

Manuscript received July 2, 1997; revised manuscript received July 1, 1998, accepted July 22, 1998.

Address for correspondence: Dr. Fumio Suzuki, The First Department of Internal Medicine, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku Tokyo 113-8519, Japan
0158.med1{at}med.tmd.ac.jp

Objectives. This study sought to define the electrophysiologic and electrocardiographic characteristics of fast–slow atrioventricular nodal reentrant tachycardia (AVNRT).

Background. In fast–slow AVNRT the retrograde slow pathway (SP) is located in the posterior septum, whereas the anterograde fast pathway (FP) is located in the anterior septum; however, exceptions may occur.

Methods. Twelve patients with fast–slow AVNRT were studied. To determine the location of the retrograde SP, atrial activation during AVNRT was examined while recording the electrograms from the low septal right atrium (LSRA) on the His bundle electrogram and the orifice of the coronary sinus (CS). Further, to investigate the location of the anterograde FP, single extrastimuli were delivered during AVNRT both from the high right atrium and the CS.

Results. The CS activation during AVNRT preceded the LSRA in six patients (posterior type); LSRA activation preceded the CS in three patients (anterior type), and in the remaining three both sites were activated simultaneously (middle type). In the anterior type, CS stimulation preexcited the His and the ventricle without capturing the LSRA electrogram (atrial dissociation between the CS and the LSRA), suggesting that the anterograde FP was located posterior to the retrograde SP. In the posterior and middle types, high right atrial stimulation demonstrated atrial dissociation, suggesting that the anterograde FP was located anterior to the SP. In the posterior and middle types, retrograde P waves in the inferior leads were deeply negative, whereas they were shallow in the anterior type.

Conclusions. Fast–slow AVNRT was able to be categorized into posterior, middle and anterior types according to the site of the retrograde SP. The anterior type AVNRT, where an anteriorly located SP is used in the retrograde direction and a posteriorly located FP in the anterograde direction, appears to represent an anatomical reversal of the posterior type which uses a posterior SP for retrograde and an anterior FP for anterograde conduction. Anterior type AVNRT should be considered in the differential diagnosis of long RP (RP > PR intervals) tachycardias with shallow negative P waves in the inferior leads.

Abbreviations and Acronyms   AH = atrium-His   AV = atrioventricular   AVNRT = atrioventricular nodal reentrant tachycardia   CS = coronary sinus   ECG = electrocardiographic   FP = fast AV nodal pathway   HA = His-atrium   HRA = high right atrium   LSRA = low septal right atrium   SP = slow AV nodal pathway

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