Unmasking of ventricular preexcitation by vagal stimulation or isoproterenol administration

Twenty-one patients were studied in whom ventricular preexcitation (VP) had been recorded in the past and had later disappeared, indicating antegrade block in the accessory pathway (AP), either spontaneously (10 patients) or under the effect of chronic treatment with amiodarone (11 patients). VP reappeared in nine cases during vagal stimulation, and in five cases during an i.v. isoproterenol infusion. Retrograde conduction over the AP was studied in four of the remaining seven patients and was found to be present in three and absent in one. Although these patients differ from the ordinary patient with concealed AP in that antegrade preexcitation had been demonstrated in the past, this study suggests that concealed VP may result from the following mechanisms: 1) an extremely prolonged refractory period in the AP, causing a rate-dependent VP that can be identified during vagal stimulation; 2) a rate-independent depression of antegrade conduction that can be reversed by isoproterenol; 3) a depression of conduction that is apparently no longer reversible. Only in the latter case is a study of retrograde conduction needed to identify the concealed VP. These three mechanisms are likely to be a natural sequence of events leading to complete antegrade block in the AP.