Atypical Atrioventricular Node Reciprocating Tachycardi Masquerading as Tachycardi Using Left-Sided Accessory Pathway

Objectives. The study was performed to document that atrioventricular node reciprocating tachycardi (AVNRT) can be associated with eccentric retrograde left-sided activation, masquerading as tachycardi using left accessory pathway. Background. The eccentric retrograde left-sided activation during tachycardi is thought to be diagnostic of the presence of left free wall accessory pathway. However, it is not known whether AVNRT can occur with eccentric retrograde left-sided activation. Methods. We studied 356 patients with AVNRT who underwent catheter ablation. Retrograde atrial activation during tachycardi and ventricular pacing were determined by intracardiac recordings, including the use of decapolar coronary sinus catheter. Results. The retrograde atrial activation was eccentric in 20 patients (6%). Eight of these patients had the earliest retrograde atrial activation recorded in the lateral coronary sinus leads, and 12 had the earliest retrograde atrial activation recorded in the posterior coronary sinus leads, with the most proximal coronary sinus electrode pair straddling the coronary sinus orifice. These tachycardias were either the fast-slow or the slow-slow form of AVNRT. The slow-fast form of AVNRT was also inducible in 17 of the 20 patients. Successful ablation of the slow pathway in the right atrial septum near the coronary sinus ostium prevented the induction and clinical recurrence of reciprocating tachycardi in all patients. Conclusions. Atypical AVNRT with eccentric retrograde left-sided activation was demonstrated in 6% of all patients with AVNRT masquerading as tachycardi using left-sided accessory pathway. Ablation of the slow pathway at the posterior aspects of the right atrial septum resulted in cure in these patients.