[Electrophysiologic findings and high frequency catheter ablation in atriofascicular and nodoventricular pathways...

So-called "Mahaim-pathways" represent a distinct subset of accessory pathways and the preexcitation syndromes with unique electrophysiologic properties. During sinus rhythm, preexcitation is minimal or absent whereas incremental atrial stimulation reveals preexcitation with a left bundle branch block like morphology. "Mahaim-fibers" exhibit long conduction times, decremental conduction properties by atrial extrastimuli or incremental atrial pacing, and conduction only in the anterograde direction. The typical atrioventricular reentrant tachycardia incorporating a "Mahaim-pathway" is a preexcited antidromic tachycardia with anterograde conduction over the accessory pathway and retrograde conduction over the AV node. "Mahaim-fibers" may be associated with dual AV node physiology or common atrioventricular accessory pathways. The original concept of "Mahaim-fibers" consisted of accessory pathways originating in the AV node and inserting into the distal right bundle branch ("nodofascicular" pathways) or the right ventricle ("nodoventricular" pathways). This understanding has been challenged by surgical interventions identifying the atrial insertion of "Mahaim-pathways" at the parietal tricuspid annulus. Later, electrophysiologic and surgical studies have confirmed the antero-to posterolateral atrial origin of these accessory pathways remote from the atrioventricular node. Therefore, the concept of nodoventricular pathways has been replaced by the concept of atriofascicular pathways. Recently, endocardial catheter mapping and radiofrequency catheter ablation have substantially contributed to the characterization of this unusual form of the preexcitation syndrome. Distinct, high-frequency activation potentials of atriofascicular accessory pathways can be recorded at the atrial insertion at the antero- to posterolateral tricuspid annulus and along the entire ventricular course up to the ventricular insertion in the right ventricular apical region near or at the distal right bundle branch. The long conduction times and the decremental conduction properties result from a delay in the interval from the local atrial activation at the atrial insertion to the activation potential of the accessory pathway whereas the conduction time between the activation potential of the accessory pathway and the local activation at the ventricular insertion is relatively constant. Overall, the current knowledge about atriofascicular pathways is indicative of a proximal AV-node-like component and a distal bundle-branch-like component and, therefore, suggestive of an accessory AV conduction system. Radiofrequency current application for ablation of atriofascicular pathways can be accomplished at their atrial insertion and along their entire ventricular course. Highfrequency activation potentials of the atriofascicular pathways identify target sites for ablation. Transient mechanical conduction block by catheter manipulation at the subannular level of the atrial insertion has also been introduced as a marker for successful ablation of these unusual accessory pathways.