Induction of atrioventricular node reentry by simultaneous anterograde conduction over the fast and slow pathways

Atrio-ventricular node reentry (AVNRT) is typically induced with an anterograde block over the fast pathway (FP) and conduction over the slow pathway (SP), with subsequent retrograde conduction over the FP. Rarely, a premature atrial complex (PAC) conducts simultaneously over the FP and SP to induce AVNRT. Previous publications have reported that conduction over the fast and slow pathway of the atrioventricular node can occur successively one after the other, thus leading to dual ventricular depolarization from what initially was a single atrial impulse. We report a case of an 18-year-old male patient referred for repeated bursts of ectopic activity. Evaluation of the patient's electrocardiographic recordings suggested the presence of dual ventricular activations for each atrial beat. The electrophysiological study revealed that the patient had simultaneous conduction over the fast and slow pathways of the atrioventricular node giving rise to a non-reentrant tachycardia, along with an absence of retrograde (ventriculoatrial) conduction, and a significant atrio-His bundle jump (A-H jump) through the slow pathway from the fast pathway during programmed electrical stimulation from the right atrium. Ablation of the slow pathway at the base of the Koch triangle yielded a cessation of the dual ventricular response, absence of the nonreentrant tachycardia and no A-H jump.