Discussion:
Focusing solely on the surface ECG findings, a deflection consistent with a retrograde P wave is observed at the terminal end of the QRS, although it is challenging to confirm. A very late coupled premature ventricular contraction (PVC) is applied, and it demonstrates evident QRS fusion. This must be by consequence “His refractory”. This PVC delays the subsequent QRS complex. Thus, one observes fusion and reset of the tachycardia, most consistent with macroreentry. The observation suggests that the retrograde limb of the circuit is an accessory pathway (AP).[1] It is worth noting that the ability of a very late coupled PVC from the RV to reset the tachycardia implies that the RV is part of the circuit or has excellent access to it. Possible explanations for this include the presence of a right AP, right paraseptal AP or a right nodoventricular AP.[2, 3]
The intracardiac tracings (Figure 1) reveal that the prevailing SVT is an orthodromic reciprocating tachycardia (ORT), and the retrograde limb is a left lateral AP with eccentric atrial activation.[4] However, this has to be reconciled with the observation that a “very late” coupled PVC from the RV resets and terminates the SVT, making a left lateral AP quite unlikely, as it would require a closer coupled PVC from the RA to access the circuit.
Figure 2 illustrates that the RVa PVC advanced the right atrial electrograms (EGMs) (His A-A 399ms), but not the left atrial EGMs (CS 7-8 A-A 437ms). Simultaneously, it caused a delay in the subsequent QRS and termination of the SVT. This is best explained by a second right AP that did not participate directly in the SVT, as depicted in the schematic diagram (Figure 2).
The cumulative evidence supports the existence of a “double loop” mechanism, in which the anterograde conduction occurs over the normal atrioventricular nodal (AVN) conduction, while retrograde conduction is over either the right or left AP. The left AP circuit activates the atrium ahead of the right AP, preventing the anterograde wave originating from the right AP from conduction into the AVN. However, the right AP still serves as a substrate for the double loop. When the PVC conducts retrogradely over the right AP, it enters the circuit and reveals the right loop. The advanced atrial activation via the right AP subsequently conducts with a long PR interval (HIS A-V 372ms), likely over a slow AVN pathway, and the tachycardia terminates. Consequently, the right AP does not directly participate in the observed SVT (bystander), but it possesses the capability to reset and terminate it. It is important to note that the tracings do not exclude the possibility of a right nodoventricular connection.
It is speculated that the termination of the tachycardia is due to the effective refractory period (ERP) of the AVN being reached, possibly because of an aborted AVN echo occurring retrogradely over the fast pathway. This renders the fast pathway refractory (retrograde concealed conduction).
After mapping the left lateral AP during RV pacing, radiofrequency ablation was carried out. Subsequent testing confirmed the presence of a right AP with retrograde conduction but without any inducible tachycardia and a long anterograde ERP.