Atrioventricular nodal conduction gap and dual pathway electrophysiology

The gap phenomenon in atrioventricular (AV) conduction is described as a block that occurs within a range of atrial coupling intervals. This block is assumed to occur between two adjacent parts of the conduction system having different refractory properties; thus, a gap would develop if the functional refractory period of the proximal unit was shorter than the effective refractory period of the distal unit. We describe a new electrophysiological mechanism based on dual pathways electrophysiology of the AV node.

In vitro experiments were performed on isolated superfused rabbit hearts. Standard electrophysiological pacing and recording techniques were used to generate conduction curves. The gap phenomenon was documented in 9 of 14 nodal preparations. With shortening of the atrial coupling interval, antegrade conduction block of the "fast" pathway wave front occurred while this impulse was still retrogradely interfering with slow pathway conduction. That is, the fast pathway wave front prevented propagation of the anterograde "slow" pathway wave front by collision or by creating a refractory barrier. This mechanism produced a gap and the block persisted until, at even shorter coupling intervals, the fast wave front penetration became insufficient and conduction was restored through the released slow pathway wave front. This mechanism was verified in AV nodal preparations with separated inputs, in which independent fast and slow wave fronts could be induced and programmed to collide.

Our results established the functional interaction of fast and slow pathway wave fronts as an important electrophysiological mechanism underlying the AV conduction gap. This mechanism may be responsible for a variety of clinically observed conduction discontinuities.