Discussion
Baseline measurements revealed sinus rhythm with narrow QRS and short HV
interval of 25ms. VA conduction was concentric and decremental with VA
block at 290ms indicative of retrograde AV nodal conduction.
Incremental atrial pacing reproducibly induced wide complex tachycardia
of LBBB morphology following AH prolongation and HV shortening (Figure
2A), suggestive of right sided decremental accessory pathway
(AP).1
Atrial extra-stimuli administered at the timing of His refractoriness
advanced the next V and the next A of the tachycardia (Figure 2B) which
is consistent with antidromic tachycardia. The differential diagnosis
includes ”long” Mahaim atrio-fascicular AP and ”short” decremental
atrio-ventricular AP. Activation mapping demonstrated earliest
ventricular activation at the antero-lateral aspect of the Tricuspid
annulus implying of ”short” decremental AP rather than the apical
portion of the right ventricle as seen in atrio-fascicular accessory
pathway.2 Unexpectedly, a discrete AP potential
(Mahaim-like) was noted at the antero-lateral aspect of the Tricuspid
annulus, at sites of early ventricular activation during antidromic
tachycardia (Figure 3A). The AP was successfully ablated via internal
jugular approach at 10 o’clock position in left anterior oblique view.
Following ablation, a unique phenomenon was demonstrated with evidence
of infra-AP potential block and AP-ventricular dissociation during
atrial pacing without pre-excitation (Figure 3B). During Three-months
follow-up the patient was free of any arrhythmias.
Accessory pathways with decremental properties connect the right atrium
or the AV node with the right ventricle or the right bundle branch.
Although the historical report by Mahaim refers to a nodo-ventricular
accessory pathway, the term Mahaim has been adapted to describe other
decremental AP’s with different anatomical features, including
atrio-fascicular and atrio-ventricular pathways.1Further classification of decremental AV pathways into “long” pathways
that insert into or near the right bundle branch and “short” pathways
that insert into the base of the right ventricle was later described by
Haı̈ssaguerre in 1995.3 The latter pathways are
characterized by atrial and ventricular insertion immediately contiguous
to the tricuspid annulus as seen in the present case in which the distal
insertion is adjacent to the Tricuspid annulus.3
Thus far, Mahaim potential, described as an AV nodal His like structure,
has been reported in ”long” atrio-fascicular and atrio-ventricular
pathways 1,2, where it also facilitates successful
ablation. Typically, catheter ablation of these pathways is accomplished
by identifying the proximal and distal insertions and the recording of a
Mahaim potential at the tricuspid annulus or on the right ventricular
free wall.
In the present case, we have found that Mahaim-like potential can be
also identified in short decremental accessory pathway in which the
earliest ventricular activation is adjacent to the Tricuspid annulus
rather than the right bundle branch or the right ventricular free wall.
The location of the Mahaim-like potential was correlated with the
earliest site of ventricular activation during maximal pre-excitation
and assisted in localization of the AP and ultimately with successful
ablation. Post ablation, a unique phenomenon of an infra-AP potential
block was documented with evidence of AP-ventricular dissociation, which
proves our concept that the Mahiam-like potential was indeed associated
with the localization and ventricular insertion of the accessory
pathway.