Tachycardia and apparent sino-atrial block due to concealed sinus node re-entry

The role of the middle intercaval area ("internodal pathway") in the genesis of atrial re-entry was studied using microelectrode techniques and the extrastimulus method in the rabbit heart. Following surgical interruption of the anterior and posterior internodal tracts, two patterns of re-entry were observed using the middle internodal pathway manifesting alternatively as tachy- and brady-arrhythmias. Re-entry which was produced by critically timed extrastimulation at the septal branch of the crista terminalis (CT) caused tachycardia reciprocating between the sinus node (SN) and intercaval area. Spontaneous re-entrant impulses were also observed, particularly following the addition of cedilanid (0.04 mg/L). In addition, in association with critical prolongation of conduction in the sino-septal area, premature discharge of the dominant pacemaker fibers was observed and resulted in the appearance of bradyarrhythmias. These were commonly manifest as bigeminy and trigeminy on the surface septal electrogram. Hence concealed sinus node re-entry could manifest itself as apparent sino-atrial block or sino-atrial re-entry tachycardia.