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(Circulation. 1996;94:1027-1035.)
© 1996 American Heart Association, Inc.

Articles

Para-Hisian Pacing

A New Method for Differentiating Retrograde Conduction Over an Accessory AV Pathway From Conduction Over the AV Node

Kenzo Hirao, MD; Kenichiro Otomo, MD; Xunzhang Wang, MD; Karen J. Beckman, MD; James H. McClelland, MD; Lawrence Widman, MD; Mario D. Gonzalez, MD; Mauricio Arruda, MD; Hiroshi Nakagawa, MD, PhD; Ralph Lazzara, MD; Warren M. Jackman, MD

the Cardiovascular Section, Department of Medicine, University of Oklahoma Health Sciences Center and the Department of Veterans Affairs Medical Center, Oklahoma City, Okla. Presented in part at the Annual Scientific Session of the North American Society of Pacing and Electrophysiology, Washington, DC, May 31, 1991.

Correspondence to Warren M. Jackman, MD, Cardiovascular Section, Department of Medicine, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd, Room 5SP-300, Oklahoma City, OK 73104.

Background Differentiation between ventriculoatrial (VA) conduction over an accessory AV pathway (AP) and the AV node (AVN) may be difficult, especially in patients with a septal AP.

Methods and Results A new pacing method, para-Hisian pacing, was tested in 149 patients with AP and 53 patients without AP who had AV nodal reentrant tachycardia (AVNRT). Ventricular pacing was performed adjacent to the His bundle and proximal right bundle branch (HB-RB), initially at high output to capture both RV and HB-RB. The output was then decreased to lose HB-RB capture. The change in timing and sequence of retrograde atrial activation between HB-RB capture and noncapture was examined. Loss of HB-RB capture without change in stimulus-atrial (S-A) interval or atrial activation sequence indicated exclusive retrograde AP conduction. An increase in S-A interval without change in His bundle-atrial interval or atrial activation sequence indicated exclusive retrograde AVN conduction. A change in atrial activation sequence indicated the presence of both retrograde AP and AVN conduction. Para-Hisian pacing correctly identified retrograde AP conduction in 132 of 147 AP patients, including all septal and right free wall APs. Retrograde AVN conduction masked AP conduction in 9 of 34 patients with a left free wall AP and 6 of 9 patients with the permanent form of junctional reciprocating tachycardia. Para-Hisian pacing correctly excluded AP conduction in all 53 patients with AVNRT.

Conclusions Para-Hisian pacing reliably identifies retrograde conduction over septal and right free wall APs, but AVN conduction may mask APs located far from the pacing site or with a long retrograde conduction time.

Key Words: pacing • conduction • atrioventricular node • electrophysiology • accessory AV pathway

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