Unusual Mechanism of PR Interval Variation and Nonreentrant Supraventricular Tachycardia as Manifestation of Simultaneous Anterograde Fast and Slow Conduction Through Dual Atrioventricular Nodal Pathways

Noninvasive recordings in a 69-year-old woman showed two distinct PR intervals of about 0.21 and 0.58 s, suggestive of dual AV nodal conduction. Various unusual mechanisms of transition from short to long and from long to short conduction intervals and phenomena of concealed conduction were due to the presence of two functionally separated intranodal pathways. Refractoriness of the slow pathway was associated with bradycardia. Episodes of tachycardia exhibited a one-to-two relationship between P-waves and ventricular activations as a consequence of simultaneous anterograde fast and slow conduction leading to double ventricular responses to single P-waves.     

Double ventricular response in dual AV nodal pathways mimicking supraventricular as well as ventricular tachycardia

Supraventricular tachycardias confined to the AV junction areusually thought to be due to reentry using a slow and a fastconducting pathway. In the case presented, a marked differenceof conduction velocity in dual AV nodal pathways and retrogradeblock in the slow conducting pathway caused a ventricular doubleresponse to a single atrial depolarization. At a critical heartrate this phenomenon occurred in a bigeminal fashion, mimickingsupraventricular as well as ventricular tachycardia.