This Article Abstract Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nawata, H. Articles by Suzuki, F. Search for Related Content PubMed PubMed Citation Articles by Nawata, H. Articles by Suzuki, F.

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

View larger version (22K): [in a new window]   Figure 1 Schematic illustration of the dissociation of atrial activation between the orifice of the coronary sinus (CSOS) and the LSRA site during extrastimulation of fast–slow AVNRT from the HRA and the CSOS. The reentrant pathway of fast–slow AVNRT is illustrated schematically as a triangular circuit comprising the anterograde FP, retrograde SP and the perinodal atrium. (I) An atrial extrastimulus is delivered anteriorly from the HRA site () during the posterior type of AVNRT in which the retrograde SP is located in the posterior septum. It is postulated in this hypothetical model that an anterior wavefront from the HRA extrastimulus (solid arrow) enters an anteriorly located FP via an anterior input and preexcites the His bundle and the ventricle, thereby resetting the tachycardia. During tachycardia resetting, the CSOS electrogram is being activated retrogradely by the previous tachycardia beat (dashed arrow), indicating atrial dissociation. (II) An atrial extrastimulus is delivered posteriorly from the CSOS site () during the anterior type of AVNRT in which the retrograde SP is located in the anterior septum. It is likewise postulated that a posterior wavefront from the CSOS extrastimulus (solid arrow) enters a posteriorly located FP via a posterior input and preexcites the His bundle and the ventricle, thereby resetting the tachycardia. During tachycardia resetting, the LSRA electrogram is being activated retrogradely by the previous tachycardia beat (dashed arrow), again indicating atrial dissociation. HBE = His bundle electrogram.

View larger version (33K): [in a new window]   Figure 2 Programmed atrial extrastimulation from the HRA and the CS orifice during the middle type of AVNRT. (A) An HRA single extrastimulus is delivered during AVNRT with a stable tachycardia cycle length of 300 to 305 ms. (B) A single extrastimulus from the CS orifice is delivered during AVNRT with a stable tachycardia cycle length of 285 to 290 ms. A0, H0 and V0 = atrial, His bundle and ventricular electrograms of ongoing tachycardia beats before the extrastimulus (S); A1, H1 and V1 = atrial, His bundle and ventricular electrograms immediately after the extrastimulus; A2 and A3 = atrial electrograms following A1; V2 and V3 = ventricular electrograms following V1; CS 3-4 (1-2) = coronary sinus (CS) electrogram recorded by the proximal (distal) pair of electrodes of a quadripolar electrode catheter positioned at the CS orifice; HBE = His bundle electrogram; V1, II = ECG leads V1 and II. Paper speed is 100 mm/s. See text for details.

View larger version (45K): [in a new window]   Figure 3 Induction of supraventricular tachycardia during right ventricular extrastimulus testing with a basic drive (S1S1) cycle length of 800 ms (case 2). (A) (S1S2 = 610 ms) The ventricular extrastimulus (S2) is conducted to the atria through an FP, with the earliest atrial activation being registered on the His bundle electrogram (HBE); the resultant A1A2 interval on the CS3-4 electrogram is 720 ms. (B) (S1S2 = 600 ms) The ventricular extrastimulus (S2) is conducted to the atria through an SP, with the earliest atrial activation being registered on the CS3-4 electrogram; the resultant A1A2 interval on the CS3-4 electrogram is 750 ms. Initiation of supraventricular tachycardia is associated with a ventricle-atrium-ventricle sequence and a prolonged A1A2 interval (720 ms 750 ms). Ae, He, Ve1 and Ve2 = atrial, His bundle and ventricular electrograms during the induced supraventricular tachycardia. Other abbreviations as in Figure 2. Paper speed is 100 mm/s.

View larger version (23K): [in a new window]   Figure 4 Typical tracings of intracardiac electrograms of three types of fast–slow AVNRT. In posterior type AVNRT, the CS3-4 (CS orifice) electrogram precedes the LSRA electrogram at the His bundle recording site by 20 ms. In the middle type, the LSRA electrogram precedes the CS3-4 electrogram by 5 ms (see the Definition of terms section). In the anterior type, the LSRA electrogram precedes the CS3-4 electrogram by 30 ms. Abbreviations as in Figure 2. Paper speed is 100 mm/s.

View larger version (72K): [in a new window]   Figure 5 Typical ECG tracings of the posterior, middle and anterior types of fast–slow AVNRT.