Effects of a Blocked Atrial Beat on the Atrioventricular Nodal Recovery Property in Patients with Dual Nodal Pathways

Dual AVN physiology can be demonstrated by a variety of maneuvers. To determine whether AVN recovery times following a blocked extrastimulus facilitate or obscure detection of dual AVN physiology, 11 patients (9-17 years) were studied with dual AVN pathways by using single and double atrial extrastimuli. With a single atrial extrastimuli, the premature atrial stimulus (A2) was coupled to basic atrial beats (A1). The fast and slow AVN recovery curves were constructed with plots of the nodal conduction time against the recovery time (A1A2,A2H2). With double atrial extrastimuli, a fixed blocked A2 beat (A2B) was followed by a scanning atrial beat (A3). The nodal recovery property post-A2B was studied by plots of A2BA3,A3H3. In all patients the recovery curve of the fast pathway post-A2B had a leftward shift when compared to that of the pre-A2B curve (i.e., the AH was shortened at the same recovery time). The window of slow pathway conduction post-A2B disappeared totally in five patients and decreased significantly in six patients (post-A2B: 26 +/- 42 ms; pre-A2B: 80 +/- 65 ms, P < 0.05). In the six patients that still had slow pathway conduction post-A2B, the slow pathway effective refractory period post-A2B was significantly less than that of pre-A2B (215 +/- 38 vs 268 +/- 16 ms, P < 0.05). The fast pathway effective refractory period post-A2B was also diminished significantly (235 +/- 62 vs 357 +/- 76 ms, P < 0.0001). The authors conclude that blocked atrial beats decrease the visibility of the slow pathway conduction.