Kaneko Yoshiaki, Tamura Shuntaro, Kobari Takashi, Hasegawa Hiroshi, Nakajima Tadashi, Ishii Hideki
Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, 371-8511 Gunma, Japan.
Rev Cardiovasc Med. 2022 Oct 28;23(11):369. doi: 10.31083/j.rcm2311369. eCollection 2022 Nov.
Our understanding of the variants of slow pathway (SP) and associated atypical atrioventricular (AV) nodal reentrant tachycardia (NRT) is still growing. We have identified variants extending outside Koch's triangle along the tricuspid annulus, including superior, superoanterior and inferolateral right atrial SP and associated atypical, fast-slow AVNRT. We review the history of each variant, their electrophysiological characteristics and related atypical AVNRT, and their treatment by catheter ablation. We focused our efforts on organizing the published information, as well as some unpublished, reliable data, and show the pitfalls of electrophysiological observations, along with keys to the diagnosis of atypical AVNRT. The superior-type of fast-slow AVNRT mimics adenosine-sensitive atrial tachycardia originating near the AV node and can be successfully treated by ablation of a superior SP form the right side of the perihisian region or from the non-coronary sinus of Valsalva. Fast-slow AVNRT using a superoanterior or inferolateral right atrial SP also mimics atrial tachycardia originating from the tricuspid annulus. We summarize the similarities among these variants of SP, and the origin of the atrial tachycardias, including their anatomical distributions and electrophysiological and pharmacological characteristics. Moreover, based on recent basic research reporting the presence of node-like AV ring tissue encircling the annuli in adult hearts, we propose the term "AV ring tachycardia" to designate the tachycardias that share the AV ring tissue as a common arrhythmogenic substrate. This review should help the readers recognize rare types of SP variants and associated AVNRT, and diagnose and cure these complex tachycardias. We hope, with this proposal of a unified tachycardia designation, to open a new chapter in clinical electrophysiology.
我们对慢径路（SP）变异型及相关非典型房室（AV）结折返性心动过速（NRT）的认识仍在不断深入。我们已识别出沿三尖瓣环超出科赫三角范围的变异型，包括上、上前和下外侧右房SP以及相关非典型、快慢型AVNRT。我们回顾了每种变异型的历史、其电生理特征及相关非典型AVNRT，以及导管消融治疗方法。我们集中精力整理已发表的信息以及一些未发表的可靠数据，展示电生理观察的陷阱以及非典型AVNRT的诊断要点。快慢型AVNRT的上型类似起源于房室结附近的腺苷敏感型房性心动过速，可通过从希氏束旁区域右侧或瓦氏窦无冠窦消融上SP成功治疗。使用上前或下外侧右房SP的快慢型AVNRT也类似起源于三尖瓣环的房性心动过速。我们总结了这些SP变异型之间的相似之处以及房性心动过速的起源，包括其解剖分布、电生理和药理学特征。此外，基于近期基础研究报道成人心脏中存在环绕瓣环的结样房室环组织，我们提出“房室环心动过速”这一术语来指代以房室环组织作为共同致心律失常基质的心动过速。本综述应有助于读者识别罕见类型的SP变异型及相关AVNRT，并诊断和治愈这些复杂的心动过速。我们希望通过提出这一统一的心动过速命名，为临床电生理学开启新的篇章。
