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Modulation of Conduction and Refractoriness in Atrioventricular Junctional Reentrant Circuit. Effect on Reentry Initiated by Atrial Extrastimulus

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Modulation of Conduction and Refractoriness in Atrioventricular Junctional Reentrant Circuit. Effect on Reentry Initiated by Atrial Extrastimulus Modulation of conduction and refractoriness in atrioventricular junctional reentrant circuit. Effect on reentry initiated by atrial extrastimulus. R Mahmud, … , M Jazayeri, M Akhtar J Clin Invest. 1988;81(1):39-46. https://doi.org/10.1172/JCI113307. Research Article The importance of activation sequence of an atrioventricular junctional reentrant (AVJRe) circuit, before delivery of an extrastimulus, has received little attention in studies concerned with clinical tachycardias. In this study a change in activation sequence was accomplished using bidirectional activation (V-A sequential pacing) during the basic drive (V1A1-V1A1). It was noted that, compared with an atrial extrastimulus (A2) after an atrial drive (A1-A1), earlier activation (by V1 impulse of the V1A1-V1A1 drive) consistently improved conduction, or decreased refractoriness, or both, in the anterograde as well as the retrograde pathway of the AVJRe circuit. In all patients, five with AV nodal reentry and six with Wolff-Parkinson-White syndrome, reentrant tachycardia could be prevented during V-A sequential pacing. In four of eleven patients, reentry was prevented despite achieving the so-called critical atrioventricular nodal delays that had previously caused reentry during control study. This finding suggested that conduction delay necessary for reentry was related to the site of block, which in turn was affected by V-A sequential pacing. We concluded that changing the activation sequence during basic drive modulates conduction and refractoriness in AVJRe circuits, and allows the study of a wide range of electrophysical factors that prevent or permit reentry. Find the latest version: https://jci.me/113307/pdf Modulation of Conduction and Refractoriness in Atrioventricular Junctional Reentrant Circuit Effect on Reentry Initiated by Atrial Extrastimulus Rehan Mahmud, Stephen T. Denker, Patrick J. Tchou, Mohammad Jazayeri, and Masood Akhtar The Natalie and Norman Soref& Family Electrophysiology Laboratory, University of Wisconsin, Milwaukee, Wisconsin 53233; and Mount Sinai Medical Center, Milwaukee, Wisconsin 53233 Abstract (AVJRe)' tachycardias (8-12), we hypothesized that if con- duction and refractoriness were affected by changing the acti- The importance of activation sequence of an atrioventricular vation sequence of the AVJRe circuit during basic drive, then junctional reentrant (AVJRe) circuit, before delivery of an ex- a new set of relationships would emerge between conduction trastimulus, has received little attention in studies concerned delay, conduction block, and coupling interval of the extra- with clinical tachycardias. In this study a change in activation stimulus. These observations could potentially result in a sequence was accomplished using bidirectional activation (V-A clearer understanding of electrophysiological factors that facil- sequential pacing) during the basic drive (VIA1-V1A1). It was itate or prevent clinical tachycardias. noted that, compared with an atrial extrastimulus (A2) after an In this study, we describe the electrophysiologic sequelae of atrial drive (Al-Al), earlier activation (by V1 impulse of the changing the activation sequence during basic drive, on the VIA,-VIA, drive) consistently improved conduction, or de- reentrant process, in both small (atrioventricular [AV] nodal creased refractoriness, or both, in the anterograde as well as reentry) as well as large (Wolff-Parkinson-White syndrome) the retrograde pathway of the AVJRe circuit. In all patients, clinical circuits. five with AV nodal reentry and six with Wolff-Parkinson- White syndrome, reentrant tachycardia could be prevented Methods during V-A sequential pacing. In four of eleven patients, reen- try was prevented despite achieving the so-called critical atrio- Study population. Eleven consecutive patients (six females and five ventricular nodal delays that had previously caused reentry males) with recurrent AVJRe tachycardias, in whom the clinical tachy- during control study. This finding suggested that conduction cardia could be reproduced by atrial premature stimulation, consti- delay necessary for reentry was related to the site of block, tuted the study group. Of the eleven patients, five had AV nodal reen- which in turn was affected by V-A sequential pacing. try and six had Wolff-Parkinson-White syndrome. The mean age ofthe We concluded that changing the activation sequence during patients was 46±13 yr. There was no evidence of underlying structural heart disease in any of these patients. Two patients, however, had a basic drive modulates conduction and refractoriness in AVJRe history of hypertension. circuits, and allows the study of a wide range of electrophysical All patients were in sinus rhythm. Right heart catheterization was factors that prevent or permit reentry. done in the nonsedated, postabsorptive state. The nature ofthe electro- physiological procedure was explained, and an informed and signed Introduction consent was obtained. Electrophysiology study. Three to four quadripolar 6F catheters Programmed electrical stimulation has proved to be a singu- were introduced percutaneously through peripheral veins and fluoro- larly useful method for study ofreentrant circuits (1-18). Since scopically positioned in the high right atrium, AV junction, coronary the original description of this method by Schmitt and Er- sinus, and right ventricular apex for local bipolar recordings (filtered at langer (1); the conduction characteristics ofthe premature beat 30-500 Hz) and electrical stimulation. In addition to the bipolar elec- have remained the focus of studies reen- trograms, three surface electrocardiographic leads (I, II, and VI) and primary concerning time lines were displayed simultaneously on a multichannel oscillo- trant circuits. What has received very little attention is the scope (VR-16; Electronics for Medicine Inc., Pleasantville, NY) and influence of activation sequence, during basic drive, on behav- recorded on magnetic tape (model 5600 C; Honeywell Inc., Medical ior of the premature beat. In a previous study, we observed the Electronics Div., Pleasantville, NY) for subsequent retrieval on photo- effect of bidirectional activation of the His-Purkinje system on graphic paper at 100 mm/s. Intracardiac stimulation was performed conduction, refractoriness, and occurrence of bundle branch with a Bloom DTU 101 digital stimulator capable of delivering pre- reentry (19, 20). Since conduction delay and conduction block mature stimuli after a basic drive of A-V sequential as well as ventricu- also play a pivotal role in atrioventricular junctional reentrant loatrial (V-A) sequential pacing with adjustable A-V (or V-A) intervals. Pacing protocol (Figs. 1-3). Initial refractory period studies were done according to previously described pacing methods (21). In gen- eral, after a basic atrial drive 400 to 700 the Address requests to Dr. Section of (Al-Al) (range, ms), reprint Mahmud, Cardiology, interval was scanned with atrial beat at of East Carolina NC 27858- diastolic premature (A2) pro- School Medicine, University, Greenville, shorter intervals until the encountered atrial mus- 4354. gressively Al-A2 A2 cle refractoriness or resulted in atrial 18 1987 and in 10 Au- repetitive responses (control Receivedfor publication May revisedform study, Fig. 1 A). After the zone of AV junctional reentry had been gust 1987. defined with the control method described above, the pacing protocol was repeated with the basic atrial drive substituted by a V-A J. Clin. Invest. (Al-Al) © The American Society for Clinical Investigation, Inc. 0021-9738/88/01/0039/08 $2.00 1. Abbreviations used in this paper: AV, atrioventricular; AVJRe, Volume 81, January 1988, 39-46 atrioventricular junctional reentrant; ERP, effective refractory periods. Effect ofActivation Sequence on Reentry 39 CONTROL Figure 1. Pacing protocol. CONTROL A A1 Al A1 * A2 A shows the control A1 A2 method, which consists es- sentially of scanning the diastole with A2 after a PRE - EXCITATION basic drive (Al-A1). The B retrograde preexcitation Al Al Al wA2 protocols are depicted in B and C. The ventricle and atrium are paced sequen- v1 V1 tially (V-A sequential pac- ing, VIA,-VIA,) and again PRE- EXCITATION C Al Al Al *A2 the diastole is scanned with A1 j A2. Al-A2 intervals and V cycle lengths of V-A se- quential drive VIA,-VIA, V1 V1 Vl are identical to that during [L control. In C the V-A inter- V - val is longer (compared with B), which results in greater retrograde preexcitation (see text, Figs. 2 and 3). VI OR sequential drive (VIA,-VIA,) (Figs. 1, B and C) at the same cycle length (V-A sequential method). The initial V-A interval was arbi- trarily selected as 0 ms. This was done to cause collision of the paced atrial and ventricular impulses in the AV node as well as in the acces- sory pathways, when present. Thus, when compared with the control method, the paced ventricular impulse during VA sequential drive caused earlier or preexcitation of segments of the reentrant circuits (i.e., AV node or accessory pathways) (see following paragraph, titled Definition of terms, and Figs. 2 and 3). After the basic V-A sequential drive (VIAI-VIA1), A2 was introduced at progressively shorter coupling Figure 3. Schematic illustration of pacing protocol in patients with intervals, identical to those during control method, and the zone of AV AV junctional reentry incorporating an accessory pathway. The junctional reentry was again determined (Figs. 1-3). The pacing pro- upper panel shows conduction through reentrant
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