Determinants of simultaneous fast and slow pathway conduction in patients with dual atrioventricular nodal pathways

Double His bundle and ventricular responses to a single atrial impulse caused by a simultaneous fast and slow pathway conduction was observed during electrophysiologic study in three patients with dual-pathway atrioventricular nodal reentrant paroxysmal supraventricular tachycardia. In patient No. 1 this phenomenon occurred during rapid atrial pacing, in patient No. 2 during both rapid atrial pacing and delivery of a single atrial extrastimulus, and in patient No. 3 during delivery of double atrial extrastimuli. Retrograde unidirectional block in the slow pathway was suggested by retrograde induction of tachycardia at a long ventricular paced cycle length and/or long ventricular coupling interval in all three patients. Our findings suggest that major determinants of this phenomenon include: (1) a sufficient conduction delay in the slow pathway so that the distal tissue is able to respond for the second time, and (2) a retrograde unidirectional block in the slow pathway so that the fast pathway impulse will not enter and collide with the oncoming slow pathway impulse.