Atrioventricular nodal re-entrant tachycardia with two functionally discrete fast pathways

We present a case with two forms of atrioventricular nodal re-entrant tachycardia (AVNRT) that revealed similar H-A-V sequences, but could be differentiated only by their retrograde atrial activation sequences. Both tachycardias were induced following anterograde slow pathway conduction, suggesting the slow pathway as the anterograde limb of the re-entry circuit. The earliest atrial activation site of one form was in the same region of the bundle of His as that of the common type of AVNRT, while that of the other form was the ostium of the coronary sinus. Properly timed extra-stimuli delivered from the atrium or ventricle during the latter tachycardia penetrated through the fast pathway without resetting the tachycardia cycle length. These rare phenomena suggest the existence of two functionally discrete fast pathways, of which the alternative pathway alters to become the more predominant retrograde limb according to time and circumstances.