Entrainment of Ventricular Tachycardia by AV Nodal Reentrant Tachycardia

Endocardial recordings from a patient with both sustained ventricular tachycardia and AV nodal reentrant tachycardia are presented that demonstrate spontaneous transient entrainment of ventricular tachycardia by AV nodal reentrant tachycardia. During electrophysiological catheterization, there were repeated episodes of spontaneous conversion from a wide to a narrow QRS morphology following the induction of ventricular tachycardia. With conversion from the wide to the narrow QRS, the ventricular deflection in the coronary sinus electrograms demonstrated an abrupt change in morphology, indicating a change in activation sequence at this site from the wavefront of depolarization emerging from the ventricular tachycardia circuit to a wavefront conducting over the His‐Purkinje system. However, the right ventricular apex electrogram demonstrated a constant morphology with a decrease in cycle length equal to that of the other intracardiac electrograms, indicating a constant direction of activation from the ventricular tachycardia circuit, and that ventricular tachycardia had been transiently entrained by AV nodal reentrant tachycardia. In addition, rapid atrial pacing during ventricular tachycardia narrowed the QRS and demonstrated transient entrainment of the right ventricular apex electrogram. Although transient entrainment of a tachycardia is evidence supporting reentry with an excitable gap as the probable mechanism, its demonstration has required the use of rapid pacing techniques. This case is a spontaneously occurring example of transient entrainment of one tachycardia circuit by another, a phenomenon that has not been previously described.

[1]  N. El-Sherif,et al.  Reentrant ventricular arrhythmias in the late myocardial infarction period: mechanism by which a short-long-short cardiac sequence facilitates the induction of reentry. , 1991, Circulation.

[2]  G. Kay,et al.  Incidence of reentry with an excitable gap in ventricular tachycardia: a prospective evaluation utilizing transient entrainment. , 1988, Journal of the American College of Cardiology.

[3]  G. Kay,et al.  Region of slow conduction in sustained ventricular tachycardia: direct endocardial recordings and functional characterization in humans. , 1988, Journal of the American College of Cardiology.

[4]  P. Brugada,et al.  Transient entrainment and interruption of atrioventricular node tachycardia. , 1987, Journal of the American College of Cardiology.

[5]  N. El-Sherif,et al.  Reentrant Ventricular Arrhythmias in the Late Myocardial Infarction Period: 14. Mechanisms of Resetting, Entrainment, Acceleration, or Termination of Reentrant Tachycardia by Programmed Electrical Stimulation , 1987, Pacing and clinical electrophysiology : PACE.

[6]  A. Waldo,et al.  Demonstration of the presence of slow conduction during sustained ventricular tachycardia in man: use of transient entrainment of the tachycardia. , 1987, Circulation.

[7]  M. Josephson,et al.  Entrainment of ventricular tachycardia by atrial depolarizations. , 1985, The American journal of cardiology.

[8]  G. Lawrie,et al.  Importance of pacing site in entrainment of ventricular tachycardia. , 1985, Journal of the American College of Cardiology.

[9]  W. Maclean,et al.  Demonstration of the mechanism of transient entrainment and interruption of ventricular tachycardia with rapid atrial pacing. , 1984, Journal of the American College of Cardiology.

[10]  P. Brugada,et al.  Entrainment as an electrophysiologic phenomenon. , 1984, Journal of the American College of Cardiology.

[11]  J. Mason,et al.  Entrainment of ventricular tachycardia. , 1984, The American journal of cardiology.

[12]  P. Brugada,et al.  Electrophysiology, Mechanisms, Diagnosis, and Treatment of Paroxysmal Recurrent Atrioventricular Nodal Reentrant Tachycardia , 1984 .

[13]  W. Maclean,et al.  Transient Entrainment and Interruption of the Atrioventricular Bypass Pathway Type of Paroxysmal Atrial Tachycardia: A Model for Understanding and Identifying Reentrant Arrhythmias , 1983, Circulation.

[14]  W. Maclean,et al.  Transient Entrainment and Interruption of Ventricular Tachycardia , 1981, Pacing and clinical electrophysiology : PACE.

[15]  M. Josephson,et al.  Supraventricular tachycardia: mechanisms and management. , 1977, Annals of internal medicine.

[16]  P. Denes,et al.  The Determinants of Atrioventricular Nodal Re-entrance with Premature Atrial Stimulation in Patients with Dual A-V Nodal Pathways , 1977, Circulation.

[17]  K. Rosen,et al.  Demonstration of dual atrioventricular nodal pathways in man. , 1974, The American journal of cardiology.