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J Cardiovasc Electrophysiol. 2019 Oct 23. doi: 10.1111/jce.14247. [Epub ahead of print]

Unusual variants of pre-excitation: From anatomy to ablation: Part III-Clinical presentation, electrophysiologic characteristics, when and how to ablate nodoventricular, nodofascicular, fasciculoventricular pathways, along with considerations of permanent junctional reciprocating tachycardia.

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Post Graduation Department, Faculdade de Ciências Médicas, Belo Horizonte, Brazil.
Arrhythmia and Electrophysiology Department, Biocor Institute, Nova Lima, Brazil.
Arrhythmia Associates, Mumbai, India.
Department of Anatomy and Cell Biology, Universidad de Extremadura, Badajoz, Spain.
Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK.
CARIM-Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands.


The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo-ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so-called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12-lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question "are they incorporated in a tachycardia circuit?". It is this information that is essential for decision-making with regard to the need for catheter ablation, and if necessary, its appropriate site.


Mahaim fibers; accessory pathways; catheter ablation; fasciculoventricular; nodofascicular; nodoventricular; permanent junctional reciprocating tachycardia; variants of pre-excitation


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