Circulation, Vol 88, 282-295, Copyright © 1993 by American Heart Association
M Akhtar, MR Jazayeri, J Sra, Z Blanck, S Deshpande and A Dhala
BACKGROUND. Atrioventricular (AV) nodal reentry is a relatively common
cause of regular, narrow QRS tachycardia. The underlying basis for this
arrhythmia is functional (and anatomic) duality of pathways in the region
of the AV node, although the exact boundaries of the reentrant circuit have
not been convincingly defined. During the more common type of AV nodal
reentry (seen in approximately 90% of cases), a slow conducting pathway is
used in the anterograde direction, and a fast pathway is operative in the
retrograde direction. In the uncommon form, the direction of impulse
propagation within the reentrant circuit is reversed. In this article, the
clinical, ECG, and electrophysiological features of AV nodal reentry as
well as approaches to therapy are discussed. METHODS AND RESULTS. Clinical
diagnosis may be made from the surface ECG. In the common type of AV nodal
reentry, the P wave is obscured by the QRS or may be present in its
terminal portion. The P wave in the uncommon form occurs late (i.e., in or
after the T wave), producing a pattern of long RP and short PR. Both forms
of AV nodal reentry are controllable with various therapeutic modalities.
For acute termination, adenosine is probably the ideal agent. Prevention of
recurrences can be achieved with several pharmacological agents, including
beta-blockers, calcium channel blockers, and class Ia, Ic, and III
antiarrhythmic agents. Curative therapy is now available with a variety of
nonpharmacological methods. However, the most promising therapy at the
present time is catheter modification of the AV node by ablation of either
the fast or slow pathway, using radiofrequency energy. Ablation of the fast
pathway carries a higher risk of second- or third-degree AV block. Slow
pathway ablation, by providing a high rate of success and minimal risk of
AV block, seems to be a more acceptable initial approach. CONCLUSIONS. AV
nodal reentry is a common cause of paroxysmal supraventricular tachycardia,
and a precise diagnosis can be made with intracardiac electrophysiological
evaluation. Although the arrhythmia responds to a variety of antiarrhythmic
agents, curative therapy can now be offered with catheter modification of
the AV node using radiofrequency energy. At the time of this writing, it
seems that catheter modification of the AV node is rapidly becoming the
therapy of initial choice in patients with symptomatic AV nodal reentrant
tachycardia requiring treatment.
ARTICLES
Atrioventricular nodal reentry. Clinical, electrophysiological, and therapeutic considerations
Sinai Samaritan Medical Center, Milwaukee, Wis. 53233.
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