© 2000 by European Society of Cardiology
Decremental conduction properties in overt and concealed atrioventricular accessory pathways
Department of Cardiology and Angiology, Elisabeth Hospital Essen, Germany
AIM: Most atrioventricular accessory pathways (AV-APs) exhibit Kent bundle physiology characterized by fast and non-decremental conduction properties. In contrast, atriofascicular APs, which are only capable of reaching slow levels of long antegrade decremental conduction, are uncommon. The aim of this study was to describe antegrade and/or retrograde AV-APs with unusual decremental properties.
METHODS AND RESULTS: Five patients with unusual decremental AV-APs underwent electrophysiological evaluation and radiofrequency catheter ablation for symptomatic tachycardias. Three were found to have structural heart disease, and three latent decremental AV-APs in the anterograde and/or retrograde direction that could not be demonstrated by routine electrophysiological testing. In Case 1, a right posteroseptal AV-AP with bidirectionally latent decremental conduction was associated with clinical antidromic circus movement tachycardia (CMT) mimicking ventricular tachycardia and orthodromic CMT, the latter inducible only with isoprenaline. In Case 2, incessant orthodromic CMT was due to a latent retrograde left posterolateral AV-AP. In both cases, double atrial responses to a single paced ventricular beat, initiating orthodromic CMT, were observed. In Case 3 with latent preexcitation unmasked by adenosine and atrial pacing, retrograde latent decremental conduction over a right posteroseptal AV-AP could be shown only with isoprenaline. This patient and the remaining two with overt preexcitation demonstrated anterograde decremental AP conduction that was discontinuous over a right posteroseptal AV-AP in Cases 3 and 4 and was continuous over a midseptal AV-AP in Case 5. In the latter case, the site of decremental conduction could be localized at the proximal AP origin. All five AV-APs were successfully ablated at the annulus level.
CONCLUSION: AV-APs with unusual decremental properties that are either latent, demonstrable only during CMT or overt, exhibiting functional longitudinal dissociation are described. These APs could be identified and successfully ablated after detailed electrophysiological analysis.
Key Words: Atrioventricular accessory pathway, latent conduction, decremental conduction, longitudinal dissociation, circus movement tachycardia
Correspondence: Jan Hluchy, MD, PhD, FESC, Department of Cardiology and Angiology, Elisabeth Hospital, Moltke Str. 61, 45138 Essen, Germany.
[1] Haissaguerre M, Cauchemez B, Marcus F. Characteristics of the ventricular insertion sites of accessory pathways with anterograde decremental conduction properties. Circulation 1995; 91: 1077–1085.
[2] Reddy GV and Schamroth L. The localization of bypass tracts in the Wolff-Parkinson-White syndrome from the surface electrocardiogram. Am Heart J 1987; 113: 985–993.
[3] Haissaguerre M, Gaita F, Marcus FI, Clementy J. Radiofrequency catheter ablation of accessory pathways: A contemporary review. J Cardiovasc Electrophysiol 1994; 5: 532–552.[Web of Science][Medline]
[4] McClelland J, Wang X, Beckman K. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994; 89: 2655–2666.
[5] Hluchy J, Wieczorek M, Tekiyeh M, Jurkovicova O, Sabin GV. Radiofrequency catheter ablation of a right atriofascicular (Mahaim) and two atrioventricular (Kent) accessory pathways in a single session. Clin Cardiol 1996; 19: 751–754.[Web of Science][Medline]
[6] Ticho BS, Saul JP, Hulse JE, De W, Lulu J, Walsh EP. Variable location of accessory pathways associated with the permanent form of junctional reciprocating tachycardia and confirmation by radiofrequency ablation. Am J Cardiol 1992; 70: 1559–1564.[CrossRef][Web of Science][Medline]
[7] Shih H, Miles WM, Klein LS, Hubbard JE, Zipes DP. Multiple accessory pathways in the permanent form of junctional reciprocating tachycardia. Am J Cardiol 1994; 73: 361–367.[CrossRef][Web of Science][Medline]
[8] Chen IC, Yeh SJ, Wen MS, Lin FC, Wu D. Radiofrequency ablation therapy in concealed left free wall accessory pathway with decremental conduction. Chest 1995; 107: 41–45.
[9] Gaita F, Haissaguerre M, Giustetto C. Catheter ablation of permanent junctional reciprocating tachycardia with radiofrequency current. J Am Coll Cardiol 1995; 25: 648–654.[Abstract]
[10] Belhassen B, Misrahi D, Shapira I, Laniado S. Longitudinal dissociation in an anomalous accessory atrioventricular pathway. Am Heart J 1984; 106: 1441–1443.[CrossRef]
[11] Chien WW and Lesh MD. Radiofrequency catheter ablation of an accessory pathway with discontinuous retrograde conduction: Potential insight into mechanism of longitudinal dissociation. Am Heart J 1993; 126: 712–715.[CrossRef][Web of Science][Medline]
[12] Atie J, Brugada P, Brugada J. Longitudinal dissociation of atrioventricular accessory pathways. J Am Coll Cardiol 1991; 17: 161–166.[Abstract]
[13] Tai YT, Campbell RWF, McComb JM. Latent functional duality in an accessory pathway. Eur Heart J 1989; 10: 380–384.
[14] Fujimura O, Smith BA, Kuo C-S. Dual ventriculoatrial conduction caused by closely approximated accessory atrioventricular pathways. Am Heart J 1992; 123: 251–252.[CrossRef][Web of Science][Medline]
[15] Przybylski J, Chiale PA, Sanchez RA. Supernormal conduction in the accessory pathway of patients with overt or concealed ventricular pre-excitation. J Am Coll Cardiol 1987; 9: 1269–1278.[Abstract]
[16] Suzuki F, Harada T, Nawata H. Retrograde supernormal conduction, gap phenomenon in concealed accessory atrioventricular pathways. PACE 1992; 15: 1065–1079.
[17] Bardy GH, Packer DL, German LD, Coltorti F, Gallagher JJ. Paradoxical delay in accessory pathway conduction during long R-P' tachycardia after interpolated ventricular premature complexes. Am J Cardiol 1985; 55: 1223–1225.[CrossRef][Web of Science][Medline]
[18] Okishige F and Friedman PL. New observations on decremental atriofascicular and nodoventricular fibers: Implications for catheter ablation. PACE 1995; 18: 986–998.
[19] Goldberger JJ, Pederson DN, Damle R, Kim Y-H, Kadish AH. Antidromic tachycardia utilizing decremental, latent accessory atrioventricular pathway fibers: Differentiation from adenosine-sensitive ventricular tachycardia. J Am Coll Cardiol 1994; 24: 732–738.[Abstract]
[20] Critelli G, Gallagher JJ, Monda V, Coltorti F, Scherillo M, Rossi L. Anatomic and electrophysiologic substrate of the permanent form of junctional reciprocating tachycardia. J Am Coll Cardiol 1984; 4: 601–610.[Abstract]
[21] Visman AGR, Hauer RNW, Demedina EOR. Unmasking of left free wall ventricular preexcitation by His bundle ablation. Br Heart J 1993; 69: 446–448.
[22] Lin F-C, Yeh S-J, Wu D. Double atrial responses to a single ventricular impulse due to simultaneous conduction via two retrograde pathways. J Am Coll Cardiol 1985; 5: 168–175.[Abstract]
[23] Miles WM, Klein LS, Minardo JD, Zipes DP. Two retrograde atrial responses from one ventricular complex in the permanent form of junctional reciprocating tachycardia. Am J Cardiol 1987; 59: 1004–1006.[CrossRef][Web of Science][Medline]
[24] Chang H-J, Wang C-C, Yeh S-J, Wu D. Double atrial responses to a single ventricular premature impulse resulting from simultaneous ventriculoatrial conductions through the normal pathway and a slow paraseptal accessory pathway. Am Heart J 1993; 125: 1434–1436.[CrossRef][Web of Science][Medline]
[25] Yamabe H, Okumura K, Tabuchi T, Tsughiya T, Yasue H. Double atrial responses to a single ventricular impulse in long RP' tachycardia. PACE 1996; 19: 403–410.
[26] Arribas F, Lopez-Gil M, Nunez A, Cosio FG. Wolff-Parkinson-White syndrome presenting as the permanent form of junctional reciprocating tachycardia. J Cardiovasc Electrophysiol 1995; 6: 132–136.[Web of Science][Medline]
[27] Touboul P, Kirkorian G, Atallah G, Cahen P, DeZuloaga C, Moleur P. Atrioventricular block and preexcitation in hypertrophic cardiomyopathy. Am J Cardiol 1984; 53: 961–963.[CrossRef][Web of Science][Medline]
[28] Bharati S, Strasberg B, Bilitch M. Anatomic substrate for preexcitation in idiopathic myocardial hypertrophy with fibroelastosis of the left ventricle. Am J Cardiol 1981; 48: 47–58.[CrossRef][Web of Science][Medline]
[29] Murdock CJ, Leitch JW, Teo WS, Sharma AD, Yee R, Klein GJ. Characteristics of accessory pathways exhibiting decremental conduction. Am J Cardiol 1991; 67: 506–510.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||