Electrophysiologic studies were performed in a patient with recurrent supraventricular
tachyarrhythmias. Sinus and paced atrial beats had QRS complexes characteristic of atrioventricular (A-V) conduction through a manifest left lateral accessory pathway (
Wolff-Parkinson-White syndrome, type A). Three distinct types of A-V
reciprocating tachycardia and three different modes of retrograde atrial activation were demonstrated. Type 1
tachycardia involved the slow A-V nodal pathway and a second (left lateral or left paraseptal) accessory A-V pathway capable of retrograde conduction only. Type 2
tachycardia was of the slow-fast A-V nodal pathway type. Type 3
tachycardia involved in heretofore undescribed circuit in that retrograde conduction occurred through an accessory A-V pathway with long retrograde conduction times and anterograde conduction through both the manifest left lateral accessory A-V pathway and fast A-V nodal pathway.
Premature ventricular beats delivered late in the cycle of this
tachycardia advanced (but did not change) the retrograde atrial activity without affecting the timing of the corresponding anterograde H deflection. In summary, this patient had five (three accessory and two intranodal) pathways participating in three different types of A-V
reciprocating tachycardia; the recurrence of these were prevented with oral
amiodarone therapy.