Adenosine-5′-triphosphate test for the noninvasive diagnosis of concealed accessory pathway

OBJECTIVES This study assessed the use of adenosine triphosphate (ATP) in the noninvasive diagnosis of concealed accessory pathway (AP) and dual atrioventricular (AV) node physiology in patients with inducible AV reentrant tachycardia (AVRT). BACKGROUND Administration of ATP during sinus rhythm identifies dual AV node physiology in 76% of patients with inducible sustained slow/fast AV nodal reentry tachycardia (AVNRT). METHODS Incremental doses of ATP were intravenously administered during sinus rhythm to 34 patients with inducible sustained AVRT involving a concealed AP and to 27 control patients without AP or dual AV node physiology. One study group patient could not complete the study and was excluded from analysis. RESULTS The AV reentrant echo beats (AVRE), or AVRT, suggestive of the presence of concealed AP, were observed after ATP administration in 24 (73%) study patients and in none of the control group. Electrocardiographic signs suggestive of dual AV node physiology were observed after ATP administration in 7 (21%) study patients and in none of the control group. Most instances of AVRE/AVRT were preceded by a slight increase (<50 ms) in PR interval. In 8 of 9 patients tested, neither AVRE nor AVRT was no longer observed following ATP administration after successful radiofrequency ablation of the AP. In the remaining patient, a different AVRE due to the presence of an additional AP was observed. CONCLUSIONS Administration of ATP during sinus rhythm may be a useful bedside test for identifying patients with concealed AP who are prone to AVRT and those with associated dual AV node pathways.