title: Fusion during entrainment of orthodromic reciprocating tachycardia is enhanced for basal pacing sites but diminished when pacing near Purkinje system end points.
abstract: BACKGROUND
  In the electrophysiological laboratory, orthodromic atrioventricular reciprocating tachycardia (ORT) can be distinguished from atrial tachycardia and atrioventricular node reentry tachycardia by identifying orthodromic and antidromic wavefront fusion during ventricular overdrive pacing (VOP). Previous work has shown that basal VOP near the accessory pathway (AP) increases the likelihood of observing fusion; however, in a third of cases, fusion is not appreciable regardless of VOP location.
  
  
  OBJECTIVE
  To explore the hypothesis that pacing near His-Purkinje system (PS) end points reduces fusion quality, which may explain patients with nonresponsive ORT.
  
  
  METHODS
  In a novel computer model of ORT, simulations were performed with a variety of AP locations and pacing sites; results were analyzed to assess factors influencing fusion quality in pseudo-electrocardiogram signals.
  
  
  RESULTS
  Entrainment by basal VOP near the AP was more likely to produce fusion visible on simulated electrocardiograms compared to entrainment by apical VOP, but this advantage was dramatically diminished when the pacing site was also near PS end points. Prediction of fusion quality based on AP proximity alone was dramatically improved when corrected to penalize for PS proximity.
  
  
  CONCLUSIONS
  These results suggest that basal VOP near the AP and far from the PS is optimal; this could be tested in patients. A denser basal ramification of PS fibers is known to exist in a minority of human hearts; our findings indicate that this unusual PS configuration is a plausible explanation for ORT cases where fusion is never observed in spite of entrainment by basal VOP near the AP.
authors.affiliation: Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD 21218, USA. pmjboyle@jhu.edu
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Boyle
authors.forename: George D
authors.initials: GD
authors.lastname: Veenhuyzen
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Vigmond
mesh_terms: D058606:Accessory Atrioventricular Bundle / Q000503:physiopathology*; D001283:Atrioventricular Node / Q000503:physiopathology*; D003198:Computer Simulation; D022062:Electrophysiologic Techniques, Cardiac / Q000379:methods*; D006801:Humans; D011690:Purkinje Fibers / Q000503:physiopathology*; D054139:Tachycardia, Reciprocating / Q000503:physiopathology / Q000628:therapy*