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An unusual form of preexcitation: Fasciculoventricular bypass tract Roderick Tung, MD, Eduard Sklyar, MD, Mark Josephson, MD From the Beth Israel Deaconess Medical Center, Boston, Massachusetts. A 35-year-old woman with a history of Wolff-ParkinsonWhite syndrome was referred to our clinic for recurrent palpitations. In outpatient consultation, she was found to have minimal preexcitation on 12-lead electrocardiogram. The QRS duration was 95 ms. In an attempt to maximize preexcitation, adenosine was administered. PR prolongation occurred without any evident increase in preexcitation (Figure 1). Response to carotid sinus massage produced similar findings. During electrophysiological study, the His-to-delta interval was measured at 30 ms. It was difficult to differentiate the His from either a split potential or fusion with the local ventricular electrogram. Pacing to Wenckebach cycle length at 400 ms demonstrated AH prolongation with constant HV interval (Figure 2A). A spontaneous Address reprint requests and correspondence: Roderick Tung, M.D., BIDMC, Cardiology, 185 Pilgrim Road, West Baker 4, Boston, Massachusetts 02215. E-mail address: [email protected]
His extrasystole resulted in preexcitation, which confirmed the presence of a subnodal bypass tract (Figure 2B). Procainamide administration did not result in accessory pathway block. No ablations were performed, and the patient was discharged with an event monitor that demonstrated sinus tachycardia. Fasciculoventricular bypass tracts are extremely rare. However, the true prevalence of this unusual form of preexcitation may be underestimated due to diagnostic underrecognition. The proof of such a pathway relies on (1) demonstration of fixed preexcitation with decremental AV node conduction and (2) preexcitation during a His extrasystole.1 Because of the close proximity to the native conduction system, reentry and clinical tachycardia have not been observed.2 Therefore, these nonparticipatory pathways are more academically intriguing than clinically relevant.
Figure 1
1547-5271/$ -see front matter © 2008 Heart Rhythm Society. All rights reserved.
Heart Rhythm, Vol 5, No 12, December 2008
Figure 2
References 1.
Josephson ME. Clinical Cardiac Electrophysiology. Techniques and Interpretations. 3d ed. Philadelphia: Lippincott Williams and Wilkins, 2002.
Gallagher JJ, Smith WM, Kassel JH, et al. Role of Mahaim fibers in cardiac arrhythmias in man. Circulation 1981;64:176 – 89.

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