Nonreentrant atrioventricular nodal tachycardia due to triple nodal pathways manifested by radiofrequency ablation at coronary sinus ostium

We report a case of complex supraventricular tachycardia manifested by radiofrequency delivery. Initially, the patient presented with orthodromic atrioventricular reentrant tachycardia via a left-sided accessory pathway that was successfully eliminated. Atrial tachycardia originating from coronary sinus ostium was also induced. Radiofrequency delivery at the coronary sinus ostium induced a narrow QRS tachycardia with irregular R-R intervals. A detailed analysis explained that the tachycardia could be a nonreentrant mechanism due to triple atrioventricular nodal pathways: an atrial excitation evokes double ventricular response due to simultaneous activation of the fast and slow pathways, and the next one activates ventricle through the intermediate pathway.