Mahaim Fibre Tachycardia: Recognition and Management

Sternick, Eduardo Back (2003) Mahaim Fibre Tachycardia: Recognition and Management. [Journal (Paginated)]

Full text available as:

[img] HTML


Dr. Gallagher et al1 wrote 22 years ago that "the role of Mahaim fibers in the genesis of cardiac arrhythmias in man has been controversial since they were first described " in the late 30's by Dr. Ivan Mahaim2. The very early reports were strictly anatomical studies2,3,4,5,6. This histopathologic quest did not end yet. Mahaim fibers were supposed to be accessory connections taking off from the His bundle and fascicles (FV-fasciculoventricular) to the right ventricle or from the atrioventricular node (NV-nodoventricular fibers) to the right ventricle. Anderson et al7 proposed 2 varieties of NV fibers, one that arises from the transitional zone and the other which inserted from the deep, compact nodal portion of the AV junction. In his pioneering work HJJ Wellens paved the road for clinical electrophysiological investigation. He was the first to study a patient with accessory pathway with decremental properties and long conduction times assuming its relationship with the fibers described long ago by "Mahaim", as reported in his doctoral thesis8 in 1971. The term nodofascicular (NF) was applied when the retrograde His bundle potential preceded the ventricular deflection, while nodoventricular pathway would be appropriate when the retrograde His bundle deflection followed the ventricular potential. It took some years to electrophysiologists realize the conceptual mismatch among the "Mahaim" physiology and structure described by Mahaim et al. An important observation was done in 1978 by Becker et al5 who found an accessory node associated with a bundle of specialized fibers measuring 1 cm and coursing through the right ventricle, mimicking a second AV conduction system located on the lateral tricuspid annulus. However, that did not change the mainstream concept of NV fibers. During the early 80's many centers started to refer patients with drug refractory tachycardias to surgical treatment. According to the current concepts at that time targeting the A-V node would be the logic strategy for curative treatment of patients with NV/NF fibers. Some courageous electrophysiologists used a new technique consisting of high-energy catheter ablation of the A-V node to treat a patient with "Mahaim" fiber, which yielded complete AV block and persistent preexcitation9. The turning point came in 1988 at the University Hospital of Western Ontario, Canada, when Klein, Guiraudon et al10 had decided to extensively freeze the A-V node and upper His bundle region of a 29 year old man and they soon realized that preexcitation did not go away. It became clear for them that his accessory pathway was not linked whatsoever to the A-V node. The next patient was luckier, and had kept intact his A-V node, while his "Mahaim fibers" were successfully severed after ice mapping produced a consistent zone of reversible block in the accessory pathway at the right lateral aspect of the tricuspid annulus. Klein's manuscript was received on August 24, 1987, and published the next year on JACC. Two months later (October 20, 1987) Circulation received a manuscript from Tchou P et al11 entitled "Atriofascicular connection or a nodoventricular fiber? Electrophysiologic elucidation of the pathway and associated reentrant circuit". From a single case report we were taught how simple it is to make sure that such pathways arise from the atrium. In recent years catheter ablation techniques have shed more light on the subject. Discrete "Mahaim" potentials that are considered surrogates of pseudo-Mahaim tissue depolarization, are used as an effective target for ablation12,13. A number of pharmacologic14 and histologic data5,6,15,16, electrophysiologic maneuvers and observations during radiofrequency catheter ablation like heat induced "Mahaim" automaticity19,20 are regarded as evidences of either an ectopic A-V node or remnants of the specialized A-V ring tissue. The NV/NF fibers are now considered a rare item but there are some convincing reports21 of narrow and regular QRS tachycardias with ventriculoatrial dissociation. The last variety which is known as fasciculoventricular pathway22 seems to play no role in clinical tachycardias but as long as it is very often associated with bypass tracts they should be correctly recognized and not targeted for ablation, avoiding unnecessary damage to the A-V node-His bundle conduction system.

Item Type:Journal (Paginated)
Keywords:Mahaim Fibre Tachycardia
Subjects:JOURNALS > Indian Pacing and Electrophysiology Journal
ID Code:4284
Deposited By: Indian Pacing and Electrophysiology, Journal
Deposited On:02 May 2005
Last Modified:11 Mar 2011 08:56

References in Article

Select the SEEK icon to attempt to find the referenced article. If it does not appear to be in cogprints you will be forwarded to the paracite service. Poorly formated references will probably not work.

1. Gallagher JJ, Smith WM, Kassell JH, Benson DWJ, Sterba R, Grant AO. Role of Mahaim fibers in cardiac arrhythmias in man. Circulation 1981;64:176-89.

2. Mahaim I, Benatt. Nouvelles recherches sur les connexions superiors de la branche gauche du faisceau de His-Tawara avec cloison interventriculaire. Cardiologia 1938;1:61-120.

3. Mahaim I. Kent's fibers and the A-V paraspecific conduction through the upper connections of the bundle of His-Tawara. Am Heart J 1947;33:651.

4. Lev M, Gibson S, Miller RA. Ebstein's disease with Wolff-Parkinson-White syndrome. Am Heart J 1955;49:724.

5. Becker AE, Anderson RH, Path MRC, Durrer D, Wellens HJJ. The anatomical substrates of Wolff-Parkinson-White syndrome: a clinic-pathologic correlation in seven patients. Circulation 1978;57:870-879.

6. Anderson RH, Path MRC, Becker AE. Stanley Kent and accessory atrioventricular connections. J Thoracic Cardiovasc Surg 1981;81:649-658.

7. Anderson RH, Becker AE, Brechenmacher C, Davies MJ, Rossi L. Ventricular preexcitation. A proposed nomenclature for its substrates. Eur J Cardiol 1975;3:27.

8. Wellens HJJ. Electrical Stimulation of the heart in the study and treatment of tachycardias. Thesis. University Park Press, Baltimore, Maryland, 1971.

9. Bhandari A, Morady F, Shen EN, Schwartz AB, Botvinick E, Scheinman MM. Catheter-induced His bundle ablation in a patient with reentrant tachycardia associated with a nodoventricular tract. J Am Coll Cardiol 1984;4:611-616.

10. Klein GJ, Guiraudon GM, Kerr CR, Sharma AD, Yee R, Szabo T, Yeung JAY. "Nodoventricular" accessory pathway: evidence for a distinct accessory atrioventricular pathway with atrioventricular node-like properties. J Am Coll Cardiol 1988;11:1035-1040.

11. Tchou P, Lehmann MH, Jazayeri M, Akhtar M. Atriofascicular connection or a nodoventricular Mahaim fiber? Electrophysiologic elucidation of the pathway and associated reentrant circuit. Circulation 1988;77:837-48.

12. Brugada J, Martinez-Sanches J, Kuzmicic B, Figueiredo MO, Matas M, Pava LF, Navarro-López F. Radiofrequency catheter ablation of atriofascicular accessory pathways guided by discrete electrical potentials recorded at the tricuspid annulus. PACE 1995;18:1388-94.

13. McClelland JH, Wang X, Beckman KJ, Hazlitt HA, Prior MI, Nakagawa H, Lazzara R, Jackman WM. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Circulation 1994;89:2655-66.

14. Ellenbogen KA, Rogers R, Old W. Pharmacological characterization of conduction over a Mahaim fiber: evidence for adenosine sensitive conduction. PACE 1989;12:1396-1404.

15. Guiraudon CM, Guiraudon GM, Klein GJ. Histologic evidence for an accessory atrioventricular pathway with AV-node-like morphology. Circulation 1988;78(Suppl II): 40.

16. Epstein MR, Saul JP, Weindling SN, Triedman JK, Walsh EP. Atrioventricular reciprocating tachycardia involving twin atrioventricular nodes in patients with complex congenital heart disease. J Cardiovasc Electrophysiol 2001;12:671-679.

17. Nogami A, Suguta M, Tomita T, Naito S, Tanigushi K, Aonuma K, Yesaka Y: Novel form of atrial tachycardia originating at the atroventricular annulus. PACE 1998;21:2691-94.

18. Gollob MB, Bharati S, Swerdlow CD: Accessory atrioventricular node with properties of a typical accessory pathway: Anatomic-electrophysiologic correlation. J Cardiovasc Electrophysiol 2000;11:922-6.

19. Braun E, Siebbels J, Volkmer M, Ouyang F, Hebe J, Willems S, Cappato R, Kuck KH. Radiofrequency-induced preexcited automatic rhythm during ablation of accessory pathways with Mahaim-type preexcitation: does it predicts clinical outcome? PACE 1997;20:1124.

20. Sternick EB, Gerken LM, Vrandecic MO. Appraisal of "Mahaim" automatic tachycardia. J Cardiovasc Electrophysiol 2002;13:244-249.

21. Hluchy J, Schickel S, Jörger U, Jurkovicova O, Sabin GV. Electrophysiologic characteristics and radiofrequency ablation of concealed nodofascicular and left anterograde atriofascicular pathways. J Cardiovasc Electrophysiol 2000;11:211-217.

22. Sallee III, D, Van Hare GF. Preexcitation secondary to fasciculoventricular pathways in children: a report of three cases. J Cardiovasc Electrophysiol 1999;10:36-42.

23. Haissaguerre M, Cauchemez B, Marcus F, Le Metayer P, Lauribe P, Poquet F, Gencel L, Clémenty J. Characteristics of the ventricular insertion sites of accessory pathways with anterograde decremental conduction properties. Circulation 1995;91:1077-1085.

24. Heal SC, Davies DW, Ward DE, Garrat CJ, Rowland E. Radiofrequency catheter ablation of Mahaim tachycardia by targeting Mahaim potentials at the tricuspid annulus. Br Heart J 1995;73:250-257.

25. Davidson NC, Morton JB, Sanders P, Kalman J. Latent Mahaim fiber as a cause of antidromic reciprocating tachycardia: recognition and successful radiofrequency ablation. J Cardiovasc Electrophysiol 2002;13:74-8.

26. Bardy GH, Fedor JM, German LD, Packer DL, Gallagher JJ. Surface electrocardiographic clues suggesting presence of a nodofascicular Mahaim fiber. J Am Coll Cardiol 1984;3:1161-1168.

27. Rodriguez LM, Smeets JLMR, Chillou C, Metzger J, Schlapfer J, Penn O, Weid A, Wellens HJJ. The 12-lead electrocardiogram in mid-septal, anteroseptal, posteroseptal and right free wall accessory pathways. Am J Cardiol 1993;72:1274-1280.

28. Grogin HR, Randall JL, Kwasman M, Epstein LM, Schamp DJ, Lesh MD, Scheinmann MM. Radiofrequency catheter ablation of atriofascicular and nodoventricular mahaim tracts. Circulation 1994;90:272-281.

29. Porkolab F, Alpert B, Scheinman MM. Failure of atrial premature beats to reset atriofascicular tachycardia. PACE 1999;22:528-530.

30. Peinado R, Merino JL, Ramírez, Echeverría I: Decremental atriofascicular accessory pathway with bidirectional conduction: delineation of atrial and ventricular insertion by radiofrequency current application. J Cardiovasc Electrophysiol 2001;12:489-492.

31. Anaclerio M, Luzzi G, Forleo C, Pitzalis MV, Rizzon P. Radiofrequency catheter ablation of a bidirectional decremental accessory atrioventricular pathway in the coronary sinus. Cardiologia 1999;44:89-95.

32. Belhassen B, Glick A. QRS complex with a left bundle branch block morphology during adenosine triphosphate test: what is the diagnosis? J Cardiovasc Electrophysiol 2002;13:519-520.

33. Ganz LI, Elson JJ, Chenarides JG. Preexcitation in a child with syncope: where is the connection? J Cardiovasc Electrophysiol 1998;9:892-895.

34.. Kottkamp H, Hindricks G, Shenasa H, Chen X, Wichter T, Borggrefe M, Breithardt G. Variants of preexcitation-specialized atriofascicular pathways, nodofascicular pathways, and fasciculoventricular pathways: electrophysiologic findings and target sites for radiofrequency catheter ablation. J Cardiovasc Electrophysiol 1996;7:916-930.

35. Klein LS, Hackett FK, Zipes DP, Miles WM. Radiofrequency catheter ablation of Mahaim fibers at the tricuspid annulus. Circulation 1993;87:738-747.

36. Cappato R, Schluter M, Weiss C, Siebels J, Hebe J, Duckeck W, Mletzko R, Kuck KH. Catheter-induced mechanical conduction block of right-sided accessory fibers with Mahaim-type preexcitation to guide radiofrequency ablation. Circulation 1994;90:282-290.

37. Belhassen B, Viskin S, Fish R, Glick A, Glikson M, Eldar M. Catheter-induced mechanical trauma to accessory pathways during radiofrequency ablation: incidence, predictors and clinical implications. J Am Coll Cardiol 1999;33:767-774.

38. Fung JWH, Chan HCK, Chan WWL, Sanderson JE. Ablation of the Mahaim pathway guided by noncontact mapping. J Cardiovasc Electrophysiology 2002;13:1064.

39. Davies DW. Treatment of "Mahaim" tachycardias by radiofrequency catheter ablation. In Camm J, Lindemans FW (eds.): Transvenous Defibrillation and Radiofrequency Ablation, Futura Publishing Co., Inc., Armonk, NY 1995:199-208.


Repository Staff Only: item control page