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(Circulation. 1999;100:1346-1353.)
© 1999 American Heart Association, Inc.

Basic Science Reports

Reentrant Pathway During Ventricular Echoes Is Confined to the Atrioventricular Node

High-Resolution Mapping and Dissection of the Triangle of Koch in Isolated, Perfused Canine Hearts

Peter Loh, MD; Jacques M. T. de Bakker, PhD; Mélèze Hocini, MD; Bernard Thibault, MD; Richard N. W. Hauer, MD; Michiel J. Janse, MD, PhD

From the Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands (P.L., J.M.T.d.B., M.H., B.T., M.J.J.); the Department of Cardiology, Heart-Lung Institute, University Hospital Utrecht, The Netherlands (P.L., R.N.W.H.); and the Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands (J.M.T.d.B., R.N.W.H.).

Background—During ventricular echoes, reentrant excitation is supposed to involve 2 functionally distinct pathways in the atrioventricular (AV) nodal area. The exact pathway of reentrant excitation is unknown. The objectives of this study were to analyze electrical activity in the AV nodal area after ventricular stimulation and during ventricular echoes and to assess the role of perinodal atrial tissue in AV nodal reentry.

Methods and Results—In 16 isolated, blood-perfused canine hearts, multiterminal electrodes were used to map electrical activity in Koch's triangle after ventricular stimulation and during ventricular echoes. The subendocardial cell layers were chemically destroyed in 3 hearts. Incisions in the posterior approach to the compact node were made in 6 hearts. The apex of the triangle of Koch was surgically dissociated from the perinodal atrial tissue in 5 hearts. Retrograde atrial activation occurred via 2 distinct endocardial exit sites. Ventricular echoes could be induced in all hearts irrespective of the atrial activation pattern. Simultaneous retrograde activation of both exit sites often preceded reciprocation. Ventricular echoes were demonstrable after chemical destruction of the endocardium and after surgical dissociation of the perinodal atrial tissue from the AV node.

Conclusions—Our data show that the reentrant pathway during ventricular echoes is confined to the AV node. The tissue that connects the node to the endocardial exit sites has to be excluded from the reentrant circuit responsible for single echoes.

Key Words: atrioventricular node • reentry • mapping • electrophysiology

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