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Challenges in Clinical Electrocardiography |

The Irregular Tachycardia That Was Not Atrial Fibrillation—Discussion

Arch Intern Med. 2011;171(22):1986-1988. doi:10.1001/archinternmed.2011.578.
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Correspondence: Dr Katz, Division of Cardiology, University of Colorado, Denver, 12401 E 17th Ave, B130, Aurora, CO 80045 (david.katz@ucdenver.edu).

Financial Disclosure: None reported.

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Figures

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Figure 2. Arrows indicate P waves; blue lines, fast pathway conduction; and red lines, slow pathway conduction.

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Figure 3. Varying conduction in a patient with dual atrioventricular (AV) nodal physiology. A, Normal conduction down the fast pathway with block in the slow pathway. This “concealment” in the slow pathway is the reason that most patients with dual AV nodal physiology do not have a double response. B, Conduction down both fast and slow pathways yielding a double ventricular response. C, When anterograde conduction occurs at a time when the fast pathway is refractory, anterograde conduction through the slow pathway then spins around the AV node, giving rise to AV nodal reentry tachycardia. AVN indicates atrioventricular node; SN, sinus node; blue arrow, fast pathway conduction; red arrow, slow pathway conduction; black arrows, conduction through the atrial myocardium.

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Figure 4. Block occurring in the atrioventricular node (AVN). A, The rhythm strip demonstrating P waves (atrial depolarizations labeled 1 and 2), fast pathway conduction (blue line), and slow pathway conduction (red line). B, P wave 1 is conducted to the ventricle down both the fast and slow pathways. C, P wave 2 is blocked in the slow pathway, which remains refractory from having just depolarized after P wave 1. Meanwhile, retrograde penetration (concealment) of the fast pathway from depolarization of the slow pathway on the previous beat leads to block of anterograde conduction of P wave 2. Long black arrows represent conduction through the atrial myocardium from the sinus node (SN) to the AVN.

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Figure 5. The patient's electrocardiogram after ablation of the slow pathway demonstrating normal sinus rhythm with left bundle branch block and 1:1 atrial-ventricular conduction.

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