Unusual features of intermediate septal bypass tracts

Intermediate septal (IS) AV bypass tracts, located along the tricuspid annulus between the His bundle and coronary sinus os, lie in close proximity to the AV node. Surgical or catheter ablation of IS bypass tracts incurs increased risk for development of complete heart block. We report additional unusual features of some IS bypass tracts that distinguish them from typical bypass tracts in other anatomic regions.

We analyzed a consecutive series of 150 patients with a history of Wolff-Parkinson-White syndrome and supraventricular tachycardia who underwent ablation of bypass tracts. We studied the incidence and characteristics of AV conduction of IS bypass tracts compared with bypass tracts in other locations. Of the 150 patients in the study, 21 had an IS bypass tract (all had anterograde AV conduction). Ten (48%) of these 21 IS bypass tracts demonstrated anterograde decremental properties with atrial pacing versus 3 (2%) of 129 non-IS bypass tracts (P < 0.001). During ablation, a change in delta wave morphology before total loss of conduction in the IS bypass tract also occurred in 3 (14%) of 21 IS bypass tracts versus 0 of 129 non-IS bypass tracts (P = 0.0004). During ablation, a change in P wave to delta wave interval occurred in 4 (19%) of 21 IS bypass tracts versus 0 of 129 non-IS bypass tracts (P < 0.0001). One IS patient exhibited retrograde Wenckebach block in the bypass tract, and two IS patients showed loss of retrograde bypass tract conduction after ablation attempts that first changed the delta wave morphology. No non-IS patient had these features (P < 0.0001 for each comparison).

Some IS bypass tracts have unusual properties that distinguish them from bypass tracts in other locations, perhaps due to the presence of multiple ventricular insertions of the bypass tract. It is possible that some cases represent true "nodoventricular" pathways.