Figure Legend
Figure 1 (A) A V-A-V response after ventricular entrainment pacing. Corrected PPI-TCL = (492-320) – (92-88) = 168 ms > 110 ms, (B) 2:1 conduction during the tachycardia.
CS = coronary sinus; HRA = high right atrium; H or HBE = His bundle electrogram; RVA = right ventricular apex.
Figure 2. Intracardiac recording (A) and 12-lead ECG(B) at the timing of a His refractory ventricular premature depolarization (VPD) during the tachycardia. The black square box in (A) is a 12-lead ECG at the same timing as that in (B). (C) RVA pacing (pacing cycle length = 300 ms) during sinus rhythm. The VPD was delivered a little earlier than the expected His bundle activation, but the QRS morphology of the His refractory VPD (Figure 2B ) had a fused QRS morphology of the sinus rhythm and ventricular pacing (Figure 2C ).
S = stimulus, SR = sinus rhythm. The other abbreviations are as shown in Figure 1.
Figure 3. At the timing of the His refractory VPD, the wavefront of the tachycardia had already reached the retrograde limb of the AVNRT circuit after the lower turnaround point. The wavefront (blue arrow) in the myocardium was directly captured by a His-refractory that VPD collided with the AVNRT wavefront (yellow arrow) in the right bundle branch or RV chamber. The collision of these wavefronts caused the fused QRS. The wavefront (broken green arrow) via the NF or NV bypass tract with the same His refractory VPD entered the retrograde limb of the AVNRT circuit, dividing it into the two directions. One wavefront (red arrow) collided with the wavefront (purple arrow) of the AVNRT after the lower turnaround point, and the other wavefront (green arrow) allowed the tachycardia to terminate due to collision with the refractory period of the retrograde slow pathway. The vertical black dashed line indicates the timing of the His bundle activation and the vertical red dashed line indicates the timing of the atrial earliest activation.
A = atrium, Ant F = antegrade fast pathway, LCP = lower common pathway, Ret S = retrograde slow pathway, the other abbreviations are as shown in Figure 1.