The dual pathway electrophysiology of the atrioventricular conduction. A new look at an old phenomenon.

Although we soon will be marking the 100th anniversary of the discovery of the atrioventricular (AV) node, the mysteries of this most complex of all parts of the conduction system of the heart remain. We are still battling controversies related to the precise morphology of the AV node and its atrial approaches. We are still debating the exact reentrant pathways of the AV nodal reentrant tachycardia. We are still uncertain if the so-called dual AV nodal electrophysiology encompasses two or more pathways, and what exactly makes these pathways in the absence of distinct insulated cables between the atrium and the AV node. It may be just surprising, in view of the above limitations, that current level of knowledge has nevertheless made possible some of the most spectacular successes in the modern cardiac electrophysiology. Thus, the cases of typical AVNRT are cured with a very high rate of success by radiofrequency ablations, increasing the quality of life of thousands of patients. AV nodal modifications are being performed to slow the ventricular rate during atrial fibrillation, although more progress is needed in this endeavor. The goal of the present review is to outline the major anatomic and electrophysiologic efforts in understanding the mechanisms underlying the dual pathway AV nodal propagation and to trace some novel approaches that promise to widen the horizon of the experimental and clinical fields.