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European Heart Journal 1991 12(3):368-377;
Copyright © 1991 by the European Society of Cardiology.
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© 1991 The European Society of Cardiology

Electrocardiographic patterns during Holter monitoring in patients with first and second degree A-V block due to ‘dual A-V nodal pathways’

M. DI BIASE, M. TRITTO, G. SABATO, M. V. PTTZALIS and P. RIZZON

Division of Cardiology, University of Bari Italy

Received 1 November 1989; revised 14 June 1990; .

Address for reprints.Matteo Di Biase, M.D., Istituto di Malattie Cardiovasco-lair, Polichinico, 70124 Bari, Italy.

Abstract

The electrocardiographic patterns, observed during 24-h Holter monitoring, of 10 patients (mean age 35 ± 22 years) with first and second degree A-V block due to dual A-V nodal pathways are reported. Recordings were selected according to the presence of: sudden and persistent prolongation of the PR interval; sudden normalization of the PR interval; ‘atypical’ Wenckebach sequences showing sudden and pronounced prolongation of any PR interval prior to the blocked P wave. Besides the already recognized pattern, new aspects were identified: (1) Wenckebach sequences in the slow and fast pathways characterized by a progressive increase in the PR interval until a blocked P wave occurred during long and short PR interval periods, respectively; (2) Wenkebach periods first in the slow and then in the fast pathway; (3) 2: 1 A-V block with a normal PR interval in the conducted beat after a Wenkebach sequence in the slow pathway; (4) Wenkebach in the fast pathway and, subsequently, in the slow one characterized by a slight prolongation of the PR interval for some beats followed by a sudden and pronounced increase in the PR interval of one beat and a subsequent progressive slight PR prolongation until a blocked P wave occurred; (5) Wenckebach sequence in the fast pathway with subsequent conduction over the slow pathway without a blocked P wave; (6) blocked P waves during both long and short PR interval periods with slight prolongation of the preceding PR interval.

The electrophysiological mechanisms involved in these electrocardiographic patterns together with the nature (anatomical or functional) of the intranodal pathways and the clinical significance of this type of block are discussed.

Key Words: First and second degree A-V block • dual A-V nodal pathways


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