Retrograde slow pathway conduction in patients with atrioventricular nodal re-entrant tachycardia

To study retrograde slow pathway conduction by means of right- and left-sided septal mapping.

Nineteen patients with slow-fast atrioventricular nodal re-entrant tachycardia (AVNRT) were studied before and after slow pathway ablation. Simultaneous His bundle recordings from right and left sides of the septum, using trans-aortic and trans-septal electrodes, were made during right ventricular pacing. Pre-ablation, decremental retrograde ventriculo-atrial (VA) conduction without jumps or discontinuities was recorded in eight patients (group 1). In six patients, retrograde conduction jumps were demonstrated (group 2) and in the remaining four patients, there was minimal prolongation of stimulus to atrium (St-A) intervals (group 3). The maximal difference (Delta St-A) between St-A intervals obtained with pacing at a constant cycle length of 500 ms and at the cycle length with maximal retrograde VA prolongation was significantly longer measured from the right His compared with the left His (122 +/- 25 vs. 110 +/- 33 ms, P = 0.02, respectively) in group 1 and group 2 (140 +/- 23 vs. 110 +/- 35 ms, P = 0.03), but not in group 3 (10 +/- 4 vs. 13 +/- 8 ms, P = 0.35). Post-ablation, Delta St-A intervals were similar between right and left His recordings (77 +/- 37 vs. 76 +/- 33 ms, P = 0.53, respectively) in group 1, (100 +/- 24 vs. 103 +/- 21 ms, P = 0.35) group 2, and (63 +/- 32 vs. 66 +/- 33 ms, P = 0.35) group 3.

In patients with typical AVNRT, retrograde conduction through the slow pathway results in earliest retrograde atrial activation on the left side of the septum and catheter ablation in the right inferoparaseptal area abolishes this pattern. These findings are compatible with the concept of slow pathway conduction by means of the inferior AV nodal extensions.