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A long RP supraventricular tachycardia with the earliest atrial activation at the His-bundle region: What is the ablation target?

      A 72-year-old woman with a prior history of catheter ablation for supraventricular tachycardia in another hospital presented with recurrent episodes of palpitations. Twelve-lead electrocardiogram recorded during the palpitation showed a long RP narrow QRS tachycardia with a second-degree atrioventricular (AV) block (Figure 1A ). At electrophysiologic study, the ventriculoatrial conduction was concentric and decremental. Programmed atrial stimulation reproducibly induced a long RP narrow QRS tachycardia. The earliest atrial activation during the tachycardia was at the His-bundle region. Intracardiac electrograms during sinus rhythm and tachycardia are shown in Figure 1B. Figure 2 shows tachycardia entrainment from the ventricle and high right atrium. What is the diagnosis of this tachycardia? What is the optimal target for ablation?
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      Figure 1A: Twelve-lead electrocardiogram during sinus rhythm and long RP narrow QRS tachycardia. A second-degree Wenckebach-type atrioventricular (AV) block was seen during the tachycardia. B: The surface and intracardiac electrograms during sinus rhythm and induced tachycardia. The earliest atrial activation during the tachycardia was at the His-bundle region (arrow). CS = coronary sinus; His = His-bundle region; HRA = high right atrium; RVA = right ventricular apex.
      Figure thumbnail gr2
      Figure 2A: Ventricular overdrive pacing during the tachycardia. B: Atrial overdrive pacing during the tachycardia. Abbreviations as in .

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