• Josselin Duchateau, Romain Tixier, Konstantinos Vlachos, Yosuke Nakatani, F Daniel Ramirez, Clémentine André, William Escande, Rémi Chauvel, Thomas Pambrun, Nicolas Derval, Frédéric Sacher, Mélèze Hocini, Pierre Jaïs, and Michel Haissaguerre.
• Hôpital Cardiologique du Haut Lévèque, CHU de Bordeaux, Pessac, France; IHU-LIRYC, Pessac, France. Electronic address: josselin.duchateau@ihu-liryc.fr.
• Heart Rhythm. 2020 Jun 1; 17 (6): 955-964.

BackgroundAtrioventricular (AV) node duality is suggested by several electrophysiological findings, none of which are strong predictors of AV nodal reentrant tachycardia (AVNRT).ObjectiveThe purpose of this study was to propose a novel maneuver to study conduction over the AV node and attempt to induce slow-fast AVNRT.MethodsVentricular-triggered atrial pacing (VTAP) with decremental VA delay was carried out in 36 consecutive patients with slow-fast AVNRT and in 21 controls after conventional electrophysiology study. Maneuvers were repeated after ablation in patients with AVNRT.ResultsVTAP resulted in a hysteretic conduction curve in 21 of 36 patients (58%) in the AVNRT group but only 4 of 21 patients (19%) in the control group (sensitivity 58; specificity 81%). This finding demonstrates sustained conduction in a slow conducting pathway and concealed retrograde conduction over a fast pathway. VTAP resulted in AVNRT induction in 15 of 25 inducible patients at baseline (60%), 4 of which were not inducible with incremental pacing or programmed atrial stimulation. VTAP resulting in a suspended p wave had 51% (39%-64%) sensitivity and 100% (89%-100%) specificity for predicting noninducibility in a given autonomic state.ConclusionVTAP is useful in patients with suspected slow-fast AVNRT. A hysteretic conduction curve demonstrates sustained conduction over a slow pathway and concealed retrograde conduction through the fast pathway, a finding in favor of slow-fast AVNRT. VTAP may facilitate AVNRT induction and proves to be an interesting complement to classic maneuvers. A suspended p-wave response specifically predicts noninducibility of slow-fast AVNRT in a given autonomic state, providing an interesting surrogate to noninducibility as a procedural end point.Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

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