DOI: 10.1161/CIRCEP.115.002971
Coexistent Types of Atrioventricular Nodal Reentrant Tachycardia:
Implications for the Tachycardia Circuit
Running title: Katritsis et al.; Typical and atypical AVNRT
Demosthenes G. Katritsis, MD, PhD1,2; Joseph E. Marine, MD3; Rakesh Latchamsetty, MD4;
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
Theodoros Zografos, MD2; Tanyanan Tanawuttiwat, MD3; Seth H. Sheldon, MD4;
Alfred E. Buxton,, MD1; Hugh
g Calkins,, MD3; Fred Morady,
y, MD4; Mark E. Josephson,
p
, MD1
1
Beth
Be
th Israel
Isr
sraeel De
D
Deaconess
aconess Medical Center, Harvard
Harv
rvar
rv
ardd Medical School, Bo
ar
Bost
Boston,
s on, MA; 2Athens
3
4
Euroclinic,
Eurroclinic,
Eu
ro
Athens,
Athens, Greece; Johns Hopk
Hopkins
p ins Hosp
Hospital,
pittal, Baltimore,
Baltimoree, M
MD;
D; University
y of Michig
Michigan
gan
Heal
He
Health
a th S
al
System,
ysste
t m, Ann
Ann
nn Arbor,
Arb
rbor
orr, MI
Correspo
Correspondence:
pond
po
nden
nd
ence
en
ce::
ce
Demosthenes G. K
atritsis,, MD,, PhD
at
Katritsis,
Division of Cardiology
Beth Israel Deaconess Medical Center
185 Pilgrim Rd, Baker 4
Boston, MA 02215.
Tel: +302106416737
Fax: +302106722535
E-mail: [email protected]
[email protected]
Journal Subject Codes: [5] Arrhythmias, clinical electrophysiology, drugs, [106]
Electrophysiology
1
DOI: 10.1161/CIRCEP.115.002971
Abstract:
Background - There is evidence that atypical fast-slow and typical atrioventricular nodal reentrant tachycardia (AVNRT) do not utilize the same limb for fast conduction, but no data exist
on patients who have presented with both typical and atypical forms of this tachycardia. We
compared conduction intervals during typical and atypical AVNRT that occurred in the same
patient.
Methods and Results - In 20 out of 1299 patients with AVNRT, both typical and atypical
AVNRT were induced at electrophysiology study by pacing maneuvers and autonomic
stimulation or occurred spontaneously. The mean age of the patients was 47.6±10.9 years (range
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
32 to75), and 11 patients (55%) were female. Tachycardia cycle lengths were 368.0±43.1 ms and
365.8±41.1 ms, and earliest retrograde activation was recorded at the coronary sinus ostium in
60% and 65% of patients with typical and atypical AVNRT, respectively. Thirteen
Thirteeen pa
ppatients
tien
ti
ents
en
ts
65%) displayed atypical AVNRT with fast-slow characteristics. By comparing cond
ductiion
(65%)
conduction
nte
teerv
rval
als during
al
duri
du
rinng
ng slow-fast
slo
low-fast and fast-slow AVNRT
T iinn the
the same patient
n , fast
faast ppathway
athway conduction
intervals
patient,
imees during the
th
he two
two types
type
ty
pess of AVNRT
pe
AVN
VNRT
RT were
weree calculated.
calcullatted
ca
ed.. The
The mean
m an
me
a difference
dif
iffe
fere
fe
r ncee be
re
betw
twee
tw
eenn re
ee
retr
trrog
ogra
r de
ra
d
times
between
retrograde
faastt ppathway
athway con
nduuction
on durin
ingg slow
in
w-faastt AVNRT,
AVN
VNRT
VN
T, and
andd anterograde
ante
an
teroograadee fastt pa
te
athw
hway
hw
a co
ondducctiion
fast
conduction
during
slow-fast
pathway
conduction
duri
riing fast-slow
fas
astt-sl
tsloow AV
AVNR
NRT
NR
T was 441.8
1.88 ± 39
9.77 m
s, aand
nd ssignificantly
igni
ig
nifi
ni
ficcant
fi
cant
ntly
ly different
dif
iffe
fere
fe
reent ccompared
ompa
ompa
pare
redd to
re
to tthe
he
during
AVNRT
39.7
ms,
estimateed between-measurements
betw
be
twee
tw
eenn-me
ee
meas
asur
as
urem
ur
emen
em
ents
en
ts eerror
rrror ((P=0.0055).
P=00.00
P=
0.00
0055
55)).
55
estimated
Conc
Co
nclu
nc
lusi
lu
sion
si
onss - Ou
on
Ourr da
data
ta pr
prov
ovid
ov
idee fu
id
furt
rthe
rt
herr ev
he
evid
iden
id
ence
en
ce th
that
at typical
typ
ypic
ical
ic
al slow-fast
slow
sl
ow--fa
ow
fast
st aand
nd aatypical
typi
ty
pica
pi
call fa
ca
fast
st--sl
st
slow
ow
Conclusions
provide
further
evidence
fast-slow
AVNRT utilize different anatomical pathways for fast conduction.
Key words: atrioventricular node, tachycardia, reentry, atypical, fast pathway
2
DOI: 10.1161/CIRCEP.115.002971
Introduction
The mechanism of atrioventricular nodal re-entrant tachycardia (AVNRT) remains elusive.1,2
Both anatomical and functional models have been proposed. There has been electrophysiologic
evidence that the right and left inferior extensions of the human AV node and the atrio-nodal
inputs they facilitate, which have been identified histologically, might provide the anatomic
substrate for the slow pathway.3-6 Data indicating the potential anatomic site of the fast pathway
are sparse. There is histologic evidence of multiple superior atrial inputs to the AV node,7-11 but
the nature of fast pathway conduction, especially during atypical AVNRT of the fast-slow type,
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is poorly understood. We have previously reported data suggesting that atypical fast-slow and
ypical slow-fast AVNRT do not appear to utilize the same limb for fast conduction.
conductio
ion.
io
n.12 Th
This
is
typical
er, was derived by observations on typical and atypical tachycardias recorded in
evidence, howeve
however,
diiff
ffeerent pati
tiien
ents
tss. We aare
re nnot
o aware
ot
awa
ware
re ooff da
dataa oon
n pati
ien
nts w
ho hhave
av
ve ex
xhi
h biite
tedd bot
othh typical
typi
ty
picall and
pi
and
different
patients.
patients
who
exhibited
both
atypical
attyp
ypic
i al tachy
tachycardia
ycarrdiia att th
the
he sam
same
amee stud
am
study.
dy.
y W
Wee hy
hypothesized
ypothes
esiized
es
ed that
tha
hat by
by comparing
com
mpariingg cconduction
onnductiion
ion in
intervals
ntervaalss
during typical
typ
ypical and
yp
n atypical
nd
aty
ypi
piccal forms
m that occur in the
the ssame
a e patient
am
paati
t ent at the
he same st
sstudy,
udyy, we could gain
nsight into
i to the
in
the properties
proope
p rtties off tthe
he ffast
ast andd sl
low pathways,
path
thway
a s, aand
ndd the
the
he mechanisms
mecha
hani
ha
nism
ni
ms responsible
responnsi
sibl
blee for
bl
insight
slow
atypical AVNRT.
Methods
Patients
Data from adult patients with AVNRT undergoing catheter ablation at five centers, Beth Israel
Deaconess Medical Center, and Rhode Island Hospital, Boston, MA, USA (2009-2013); Athens
Euroclinic, Greece (2007-2014); the Johns Hopkins Hospital, Baltimore, MD, USA (2011-2014);
and the University of Michigan Health System, Ann Arbor, MI, USA (2009-2014), were
analyzed. The subjects of this study were the patients in whom both typical and atypical AVNRT
3
DOI: 10.1161/CIRCEP.115.002971
were induced in the same procedure and in whom tracings suitable for evaluation were available.
All patients were studied in the post-absorptive state, under mild sedation, and after all
antiarrhythmic agents had been discontinued for more than 5 half-lives. No patient had received
amiodarone for the preceding three months. The study received approval from our institutional
review boards.
Definitions
AVNRT was diagnosed by fulfillment of established criteria during detailed atrial and ventricular
pacing maneuvers,1,2 and subsequent abolition of the tachycardia by anatomic ablation of the
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
slow-pathway. Typical (slow-fast) AVNRT was defined by an atrial-His/His-atrial ratio (AH/HA)
atrial
>1, and HA interval ”70 ms. Atypical AVNRT was defined by delayed retrograde
retrograd
de at
atri
rial
ri
al
activation with HA>70 ms. If the AH was <200 msec and the AH<HA, the atypical form was
characterized
AH>200
mss an
AH>HA,
was
slowch
harrac
a terizedd ass ffast-slow.
a t-sslo
as
low.
w. IIff AH
H>2
>200
000 m
andd AH>H
>HA,, tthe
>H
he aatypical
t pi
ty
pica
call fo
ca
fform
rm
mw
as cconsidered
onsi
on
side
si
d re
redd sl
low
owslow.
with
prolonged
AH
interval
>200
with
AH<200
and
low
w. Tachycardias
Tachycarddias wi
ithh a pr
rolonged
rol
lo d A
H inte
ervval >
2000 ms but
but AH<HA,
AH<
H<HA,, or
H<
or w
itth AH
H<2
200 ms an
nd
variable
intervals
same
different
episodes,
were
AH>HA,
A,, oorr with
th
h varia
iabl
ble interv
bl
rvvals during the
he sam
amee or dif
am
ffe
ferent episo
sodes, w
so
e e cl
er
classified as
indeterminate.
ndeterminate.
t De
D
Details
tail
ta
ils off our m
il
methodology
eth
thodo
d logy for
for measurements
measure
r ments
t off iintervals
nterva
nt
vaals during
durin
i g tachycardia
tach
tach
chyc
ycar
yc
arddia have
ar
been described elsewhere.12
Hypothesis
If the anatomical models are correct, AVNRT types that coexist in the same patient may utilize
the same distinct limbs of the circuit regardless of the tachycardia type, and retrograde atrial and
anterograde ventricular activation should utilize the same anatomical pathways in all forms of
AVNRT. Therefore, conduction times such as the atrial-His (AH) and His-atrial (HA) intervals
during types of tachycardia coexisting in the same patient can be calculated and used to provide
data on the characteristics of the fast and slow circuit limbs.
Figure 1 depicts one of the proposed fixed, anatomical models of slow-fast and fast-slow
4
DOI: 10.1161/CIRCEP.115.002971
AVNRT. According to this model, during AVNRT, the tachycardia circuit is confined within the
AV node region, and activation of the atrium takes place following activation of the retrograde
pathway. Thus, during typical, slow-fast AVNRT the HA interval represents the time difference
between activation of the His bundle and activation of the atrium, this is HA=Fr+A-H, where Fr
is the time the impulse travels retrogradely along the fast pathway, A is the time the impulse
travels from the AV node to right atrium as recorded by the electrode positioned on the His
bundle, and H is the time the impulse travels from the AV node to the His bundle. Similarly, the
AH interval represents the time difference between activation of the right atrium as recorded by
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the catheter positioned on the His bundle, and the next activation of the His bundle. This is
AH=Sa+H-A, where Saa is the anterograde conduction along the slow pathway, H iiss the
the time
time the
the
mpulse travels from the AV node to the His bundle,, and A the time the impulse travels from
f
impulse
the
AV nnode
ode to rright
ight
ig
htt atrium.
atriu
um.
m During
Dur
u in
ng atypical,
atyp
at
y ic
yp
ical
al, fa
al
fast
st--slow
st
w AVNRT,
AVN
NRT
RT,, HA=Sr+A-H,
HA
A=Sr
Sr+A
+ -H,
+A
H whe
here
he
re Sr
S iss tthe
h ttime
he
ime
im
fast-slow
where
equuired for the iimpulse
mpulse
se to travel
trrav
vel retrogradely
retr
trog
oggraadelly along
alonng thee slow
slo
low
w pathway,
path
hway, A iiss the
the timee the
the impulse
im
mpul
ullsee
required
ravels fr
rom
o thee A
V no
node
d to righ
ght atrium, andd H is the
gh
the
h time
me the impulse
impul
u se travels
trave
vels from
ve
fro
rom the AV node
travels
from
AV
right
His bundle.
bundl
dle. AH=Fa+H-A,
dl
AH=F
H=Fa+H
+H-A
+H
A, where
whhere Fa
F is
i the
the
h ti
timee required
required
i d for
for ante
tero
te
rogradde con
ro
ndu
duct
ctio
ct
ionn along
io
too the His
anterograde
conduction
the fast pathway, H is the time the impulse travels from the AV node to the His bundle, and A the
time the impulse travels from the AV node to right atrium. Assuming that conduction velocity
over the slow pathway is similar in the anterograde and retrograde direction (ie Sa=Sr), as
happens in some types of accessory pathways,13 and retrograde atrial activation takes similar
paths in all forms of AVNRT in the same patient, then HA (f-s) + AH (s-f) = (Sr+A-H) + (Sa+HA) = 2S. Since TCL = AH+HA=S+F, by definition, derivation of the S interval can provide the
value of F. If derived Fr values are significantly different than those for Fa, then the possibility of
typical and atypical AVNRT utilizing the same anatomical limb for fast conduction is unlikely.
5
DOI: 10.1161/CIRCEP.115.002971
Statistical analysis
Data normality was assessed using the D’Agostino – Pearson test. Continuous, normally
distributed variables were presented as mean ± standard deviation (SD). Categorical data were
expressed as frequencies (percentages). Statistical analysis was performed to compare the
measured difference between Fr and Fa (Fr-Fa) to the anticipated difference considering the
variability between repeated measurements on the same subject.14 In order to determine the
maximum difference that could be attributed to between measurements variability, we measured
the AH interval, HA interval, and TCL during the typical form of AVNRT and computed Fr
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
twice for each patient. The mean absolute value of the difference between these two
measurements and its standard error (3.69ms±0.44ms) was used to estimate 95%
% confidence
con
onfi
f de
fi
denc
ncee
nc
ntervals (CI)) for tthe
he between-measurement error ((2.72
2.72 – 4.66ms). Accordingly, using one
intervals
amp
mple t-test,
t-testt, wee compared
com
mpa
pare
reed thee mean
mean
a of
of th
tthee absolute
absolu
ab
utee values
vallue
uess of
o Fr-Fa
Fr-F
-Faa to
t the
the upper
upp
ppper bound
bou
o ndd of
of the
the
sample
95
5% CI (4.7ms).. To
To further
fuurtther
th examine
examine
xa
e th
he rrelation
elaatio
on ooff m
eaasu
sure
reed Fr-Fa
Faa valu
uess to
o an
an expected
exppec
pecteed
95%
the
measured
values
between-me
m asurrem
e en
nt er
error, w
mea
easu
sure
su
r d Fr-Fa
Frr Fa valuess together
er wit
ithh 95% CIs of
it
between-measurement
wee have plottedd measured
with
between-measureme
mentt error, in
i a manner an
alogous
l
t aB
to
land-Al
d Al
Alttman
n pplot.
lott. S
lo
tati
tist
ti
sttic
ical
al analyses
analyses
between-measurement
analogous
Bland-Altman
Statistical
were performed using IBM SPSS Statistics v.22 (IBM Corp, Armonk, New York, USA). All
tests were two-tailed, and P-values < 0.05 ZHUHFRQVLGHUHGVLJQL¿FDQW
Results
Patients
In total, 1299 patients with AVNRT were studied at Beth Israel Deaconess Medical Center, and
Rhode Island Hospital, Boston, MA, USA (n=188); Athens Euroclinic, Greece (n=287); the
Johns Hopkins Hospital, Baltimore, MD, USA (n=271); and the University of Michigan Health
System, Ann Arbor, MI, USA (n=553). Using the criteria mentioned above, 20 patients, had both
6
DOI: 10.1161/CIRCEP.115.002971
typical and atypical AVNRT during the electrophysiology study. The mean age of all patients
was 47.6+-10.9 years (range 32 to75), and 11 patients (55%) were female. Among these 20
patients, 13 patients (65%) displayed atypical AVNRT with characteristics compatible with the
fast-slow type according to both the AH<HA and AH<200 ms, and 4 patients (20%) had slowslow form of AVNRT. The remaining 3 patients (15%) could not be reliably classified due to
inconsistent AH and HA/AH patterns or variable intervals. Conduction intervals during
tachycardias are shown in Table 1. Typical anterograde conduction jumps during atrio-ventricular
conduction curves were demonstrated in 11 out of 20 patients. Typical retrograde conduction
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jumps were not demonstrated in any patient.
Mode of induction and earliest atrial retrograde activation
Typical tachycardia
tachyycarddia induction during atrial pacing was seen in 8 out of 20 patients, and in two of
hem
m only following
fooll
llow
ow
win
ingg isoproterenol
isop
is
opro
op
rote
ro
t reeno
noll in
iinfusion.
fusi
fu
sion
si
on.. Ta
on
Tachy
ycaardiaa in
indu
ductio
du
io
on wi
with
h typical
typ
y ical
all anterograde
ante
an
tero
te
r gr
g ad
adee
them
Tachycardia
induction
co
ondduction jump
ps wass sseen
een iin
n 9 pati
ien
e ts. In tw
two patients,
paatiien
nts
ts,, typical
typpica
ty
pic l AVNRT
AVNR
AV
RT wa
as in
iinduced
ducced
ced wit
w
ith
conduction
jumps
patients.
was
with
ventricula
laar pacing
n and
ng
d the
the
h use of
of three extras
sti
t mu
muli
li.. Atypical
li
Atypic
ical AVNRT
R was induced
ind
n ucced
e by atrial
ventricular
extrastimuli.
pacing iin
n 3 patients,
pati
tients
ts,, andd by
ts
b ventricular
venttriicular
l pacing
paciing in 7 patients
pat
attients
t (in
(i on
ne pati
tieentt with
ti
ith isoproterenol).
isooprrot
oter
ereenol).
er
one
patient
No typical retrograde conduction jumps were seen at induction; in one patient 2:1 retrograde
conduction was noted at tachycardia induction. Atypical AVNRT was induced following atrial or
ventricular ectopic beats in 2 patients. Earliest retrograde activation was variable and
documented at the coronary sinus ostium in the majority of patients for both types of AVNRT.
In all patients, both tachycardias were abolished following anatomical slow pathway
ablation.
Slow-fast vs fast-slow AVNRT
Using the strict criteria in this study, 13 patients had both slow-fast and fast-slow AVNRT
according to our definitions. Patient characteristics and conduction intervals are presented in
7
DOI: 10.1161/CIRCEP.115.002971
Table 2. Conduction times over the fast pathway during slow-fast AVNRT (Fr) and during fastslow AVNRT (Fa) are presented for each patient in Figure 2A. The mean difference between Fr
and Fa was 41.8 ± 39.7 ms. This was significantly different compared to the estimated betweenmeasurements error (P=0.0055)(Figure 2B).
Discussion
Our study represents the largest series of AVNRT cases with coexistence of both typical and
atypical forms of which we are aware. Interestingly, in the majority of these patients, earliest
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retrograde atrial activation was detected at the coronary sinus ostium in both types of tachycardia.
This is in keeping with previous observations on atypical AVNRT.12
Most patients with atypical AVNRT display the fast-slow variety. Our results
resullts argue
against
ag
gai
ainnst the conventional
co
notion of a common anatomical
anatom
omical fast path
om
pathway
hwa
w y th
that
hat supports both slowfastt and fast-slow
fa
wA
AVNRT
VNR
NRT by condu
NR
conducting
d ctiingg op
opposite
ppoositee ddirections.
ireccti
tion
ons.. Derived
on
Deerivved F
Frr an
andd F
Faa val
values
alue
al
uees were
were
significantly
ign
nif
ific
ican
ic
antl
an
tlyy different
tl
diiff
ffer
eren
er
entt iin
en
n oour
ur st
study,
tud
udyy, and tthis
hiss di
hi
difference
diff
ffer
ff
erren
ence
ce is uunlikely
nlik
nl
ikel
ik
ely to be
be due
due to
t a betweenbetw
be
tweeentw
measurements
measurem
emen
em
ents
en
ts eerror.
rror
rr
or. Si
or
Sinc
Since
ncee CL
nc
CL=F
CL=F+S,
=F+S
=F
+S, an
+S
andd ac
acco
according
corddin
co
ingg to the
the fixed
fix
ixed
ed anatomical
ana
nato
tomi
to
mica
mi
call mo
ca
mode
model,
del,
de
l, bboth
othh ty
ot
types of
A
VNRT utilize
tili the
th same slow
l pathway,
th
di t comparison
i
th
d ti
AVNRT
an iindirect
off ffastt pathway
conduction
during typical and atypical AVNRT could be also derived by comparing tachycardia cycle
lengths. However, changes in autonomic tone, either spontaneously or following isoprenaline
infusion, do not make such a comparison legitimate. Our method of deriving slow pathway
values by taking into account both tachycardias in the same patient represents an attempt to
overcome this limitation.
Considering the anatomic models of the AVNRT circuit, our results provide further
evidence in support of our proposed scheme of re-entry along the posterior nodal extension in all
forms of atypical AVNRT.12 Attempts to provide a functional circuit model have also been made
8
DOI: 10.1161/CIRCEP.115.002971
by reference to contextual considerations, such as the anisotropic conduction properties of the
transitional area between the atria and the AV node,15-20 and variability in the space constant of
tissue and poor gap junction connectivity, due to differential expression of connexin isoforms in
the nodal area.21,22 Regardless of the nature of the reentry circuit in AVNRT, our results suggest
that anterograde fast conduction during atypical AVNRT is distinct from retrograde fast
conduction during typical AVNRT.
Study Limitations
The main limitation of our study is that we considered a hypothetical model based on theoretical
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assumptions such as similar anterograde and retrograde conduction velocities for the slow and
fast pathways in both types of AVNRT. Although studies on orthodromic and antidromic
an
nti
tidr
drom
dr
omic
om
ic
lateeral accessory
r pathways do not indicate fundamental differences in conduction
conduction of lateral
veelo
oci
c ty, whether
whhet
ethe
herr th
tthis
iss is
is true
trrue also
als
lsso for
for decremental
decr
de
crem
cr
men
ental AV nod
odal
od
al ppathways
athw
hway
hw
ayss iss nnot
ay
o kno
ot
nown
no
wn.. Th
wn
he
velocity,
nodal
known.
The
co
omp
mparison of AV nod
dal
al con
nduuctionn pr
roppertiiess wi
ithh th
hat ooff by
ypasss tractss iiss ccomplex.
om
mplex
x. IItt iiss like
ely
y
comparison
nodal
conduction
properties
with
that
bypass
likely
hat much
mucch of thee difference
diffeereenc
n e between
betw
tw
ween anterograde
anterogrrad
a e an
andd retrog
oggrade con
ndu
d ction properties
p opper
pr
e ties relates to
that
retrograde
conduction
mpedance mi
ismat
atch
at
ch bbetween
etween
t
vent
tricular
l or atri
iall mus
u clle andd th
that
at off th
thee bypass
by
ttract.
r ct
ra
ct.. T
his does
impedance
mismatch
ventricular
atrial
muscle
This
not directly parallel the situation in the AV node, and there are no data to allow any definitive
conclusion in this respect. In addition, retrograde atrial activation, in particular, may not take
similar paths in all forms of AVNRT as accepted in purely anatomical models. Finally, one could
argue that using the same data and the same formula, an investigator who believes that there is a
single fast pathway can 'prove' that there are discrete slow pathways. The fact that anatomic slow
pathway ablation abolishes both typical and atypical AVNRT argues against such a hypothesis,
although it cannot not exclude the possibility of anatomically close, but discrete, slow pathways
affected by anatomical ablation.
9
DOI: 10.1161/CIRCEP.115.002971
Conclusion
Our data provide further evidence that slow-fast and fast-slow AVNRT that slow-fast and fastslow AVNRT do not utilize the same anatomical pathway for fast conduction.
Conflict of Interest Disclosures: None.
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Table 1: Conduction intervals during typical and atypical AVNRT of all types.
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
AVNRT type
CL
(ms)
AHtachy (His)*
(ms)
HAtachy (His)*
(ms)
HAtachy (pCS)+
(ms)
Earliest retrograde
atrial activation
Typical AVNRT
368.0±43.1
281.6±47.1
67.3±14.6
62.0±13.7
pCS (60%)
Atypical
cal AVNR
365.8±41.1
128.2±58.0
217.4±66.2
202.3±70.1
pCS
pC
S (65%)
(65%
(6
5%))
5%
*: in 7 pati
patients,
tiien
ents
ts,, th
ts
thee HR
HRA
A el
electrogram
lec
ecttrogram
tr
was used for measurements, due too ov
over
overlap
errlap of the atrial and ventricular
ventricu
cu
ulaar electrograms on His.
asu
sureed in
su
i 17 patients.
paati
tien
en
nts.
+: measured
achyc
chyc
ycardia cycle length,
leng
le
gth
h, AH
A ta
ach
chy
y: at
atri
r al too His
ri
His in
inte
terv
rval
rv
al dduring
urrin
ingg ta
tachyc
carddia, HA ta
tach
chyy: Hi
ch
is too ri
righ
g t at
gh
tri
rium
u int
um
ter
erva
vall dduring
va
u ingg ta
ur
ach
chyc
ycar
yc
ardi
ar
dia.
di
a
CL: tachycardia
tachy:
atrial
interval
tachycardia,
tachy:
His
right
atrium
interval
tachycardia.
12
DOI: 10.1161/CIRCEP.115.002971
Table 2. Patients with typical (slow-fast) and atypical AVNRT of the fast-slow type.
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
Fast-slow AVNRT
Slow-fast AVNRT
Pt No
Age
Sex
CL
AH tachy
HA tachy
CL
AH tachy
HA tachy
1
57
M
410
320
62
40
F
395
325
60
154
78
220
2
394
275
187
1 7
18
3
36
F
345
248*
77*
450
12
128
300
4
47
M
380
313
47
360
8
80
260
5
444
4
M
370
300
50
3555
355
86
249
6
555
5
M
4 0
40
400
3 0
31
310
6
62
3844
1 6
15
156
2 8
20
208
7
75
M
3225
325
2229*
229*
77*
3441
341
1007
107
2 8
21
218
8
448
M
4100
3005*
305*
8 *
81
81*
4665
465
93
93
33
336
9
322
F
280
280
211
211
56
377
377
152
152
200
200
10
53
M
40
404
2722*
2*
272*
95*
95*
4000
40
3
35
325
11
43
F
39
395
335
335
58
355
355
85
253
12
55
F
370
294
50
350
30
299
13
58
F
376
289
60
356
59
270
*: due to overlap of ventricular and atrial electrograms, the HRA electrogram was used for measurements.
CL: tachycardia cycle length, AH tachy: atrial to His interval during tachycardia on the His-recording electrogram, HA tachy: His to right atrium
interval during tachycardia on the His-recording electrogram.
13
DOI: 10.1161/CIRCEP.115.002971
Figure Legends:
Figure 1: Depiction of conduction and resultant AH and HA during typical and atypical AVNRT
types. Please see text for details.
Fr: retrograde conduction over the fast pathway; Fa: anterograde conduction over the fast
pathway that is utilized by the fast-slow form; S: conduction over the slow pathway
(anterogradely or retrogradely); A: conduction from the AVN node to right atrium as recorded by
the electrode positioned on the His bundle; H: conduction from the AVN to His bundle; HA:
Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
time difference between activation of the His bundle and right
atrium; AH: time difference between activation of right atrium and the next His.
Figu
Fi
ure 2: A:: Conduction
Cond
Co
nducti
nd
tiion times
tim
imess over
ove
verr the
th
he fast
f st pathway
fa
pat
a hw
way
y dur
urin
ur
ingg slow-fast
in
s ow
sl
w-fa
fast
fa
s AVNRT
AVN
V RT
T (Fr)
(Fr
Fr)) andd du
duri
ring
ri
ng
Figure
during
during
fa
astt-slow AVNRT
RT (Fa)
(Faa) ffor
or eac
achh pati
ac
ien
e t. C
orrres
responnding
di g values
val
aluues
ues for
foor each
each ppatient
at entt are cconnected
atie
onnneected
fast-slow
each
patient.
Corresponding
with lines.
lines
ess. B: Scatterplot
Sca
catterpl
ca
p ot of thee difference
pl
d fference inn cconduction
di
onndu
duct
c ion ti
ime
m s overr tthe
he fast pa
ppathway
th
hwa
w y during
times
low-fastt AVNRT
AVN
VNRT
RT (Fr)
(Fr
Fr)) andd du
dduring
ring
i fast-slow
fastt-slow
l AVNRT
AVN
VNRT
RT (Fa)(Fr-Fa)
(Fa
F )(F
(Fr-Fa
Fa)) ag
ains
ins
nstt me
m
an con
ndu
duct
ctio
ct
ion time
io
slow-fast
against
mean
conduction
over the fast pathway for each patient. The 95% confidence intervals of the estimated betweenmeasurements error are superimposed (dotted lines) for comparison.
14
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Downloaded from http://circep.ahajournals.org/ by guest on June 18, 2017
Coexistent Types of Atrioventricular Nodal Reentrant Tachycardia: Implications for the
Tachycardia Circuit
Demosthenes G. Katritsis, Joseph E. Marine, Rakesh Latchamsetty, Theodoros Zografos, Tanyanan
Tanawuttiwat, Seth H. Sheldon, Alfred E. Buxton, Hugh Calkins, Fred Morady and Mark E.
Josephson
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Circ Arrhythm Electrophysiol. published online July 8, 2015;
Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue,
Dallas, TX 75231
Copyright © 2015 American Heart Association, Inc. All rights reserved.
Print ISSN: 1941-3149. Online ISSN: 1941-3084
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World Wide Web at:
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