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JACC: CLINICAL ELECTROPHYSIOLOGY
VOL. 2, NO. 2, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 2405-500X/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacep.2015.10.011
Atrioventricular Reciprocating Tachycardia
Mediated by Twin Atrioventricular Nodes
Antonio Frontera, MD, Darren Hooks, MD, PHD, Bernard Kreitmann, MD, PHD, Jean-Benoit Thambo, MD, PHD,
Michel Haïssaguerre, MD, Nicolas Derval, MD
A
21-year-old man with univentricular and
atrioventricular
uniatrial heart came for a third attempt at
However, entrainment of the circuit was perfect
re-entrant
tachycardia
(AVRT).
ablation of recurrent supraventricular tachy-
when pacing at high output from the anterior and pos-
cardia. He had undergone a previous cardiac surgery
terior AV connections (Figure 2), and poor when pacing
of a Blalock–Taussig shunt, and bidirectional Glenn,
at low output from the same sites (Figure 3). This can
and the electrophysiological study revealed an atrio-
only be explained by an AVRT circuit using twin AV
ventricular (AV) node very posterior and low in the
nodes, with capture of the His bundles at high output,
atria, close to the inferior vena cava junction. Further
and capture of only ventricular tissue at low output.
mapping allowed us to identify a second sharp electro-
High- and low-output entrainment pacing at both
gram of His bundle, timed late in the QRS complex,
His-bundles demonstrated to be instructive in estab-
located anteriorly to the annulus (Figure 1). Atrial
lishing mechanism of the tachycardia. Failure of
pacing dissociated this signal from both atrial and
His-synchronous ventricular premature beats to reset
ventricular activity, indicating a distinct tissue type.
tachycardia may be explained by the decremental
Ventricular pacing documented a retrograde atrial
properties of the retrograde limb, and the long ven-
activation decremental exclusively via the “anterior”
tricular post-pacing interval may be consistent with
pathway, supporting the presence of a second AV
previously described slings of specialized conduction
node. Supraventricular tachycardia was easy induced
tissue traversing the ventricle.
with atrial burst pacing, having cycle length of 450
ms with 1:1 AV relationship and ventriculo-atrial
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
time of 190 ms. Ventricular premature beats synchro-
Antonio Frontera, Hôpital Cardiologique Haut Lèvé-
nous to the “posterior” His failed to reset the tachy-
que, CHU Bordeaux, Bordeaux 33600, France. E-mail:
cardia
[email protected].
and
entrainment
performed
from
the
ventricular apex had a post-pacing interval of 140 ms.
These 2 data supported a mechanism other than
KEY WORDS AVRT, congenital, twin AV nodes
From the Hôpital Cardiologique Haut Lèvéque, CHU Bordeaux, Bordeaux, France. Dr. Frontera received a grant from the European
Heart Rhythm Association outside this work. All other authors have reported that they have no relationships relevant to the
contents of this paper to disclose.
Manuscript received September 8, 2015; revised manuscript received October 8, 2015, accepted October 15, 2015.
Frontera et al.
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 2, NO. 2, 2016
APRIL 2016:248–50
AVRT in Twin AV Nodes
F I G U R E 1 Anteroposterior 3-Dimensional CARTO Map of the Atrium
The yellow dot shows the location of the “posterior” node while the pink dot represents the “anterior” node. Local electrograms in sinus
rhythm are displayed.
F I G U R E 2 Pacing From the “Posterior” His Bundle: High Output
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250
Frontera et al.
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 2, NO. 2, 2016
AVRT in Twin AV Nodes
F I G U R E 3 Pacing From the “Posterior” His Bundle: Low Output
APRIL 2016:248–50