Unmasking of left free wall ventricular preexcitation by His bundle ablation

His bundle ablation was performed in a 48 year old man with drug refractory orthodromic atrioventricular reentrant tachycardia and paroxysmal atrial fibrillation. Reentry was caused by a left free wall concealed accessory pathway. Interruption of the His bundle by low energy direct current shock (25 J) was quickly followed by anterograde conduction via the accessory pathway, with various forms of advanced block. The combined effect of unfavourable anterograde conduction (prolonged anterograde effective refractory period and decremental conduction), the left lateral location of the accessory pathway and intra-atrial conduction delay on one side, and normal conduction via the atrioventricular node and His bundle with retrograde concealed conduction into the accessory pathway on the other side resulted in masking of the anterograde conduction capability of the anomalous pathway. This observation does not seem to invalidate the choice of His bundle ablation in similar cases.