"AV nodal" reentry: Part II: AV nodal, AV junctional, or atrionodal reentry?

The classical model of "atrioventricular (AV) nodal" reentrant tachycardia suggests that the reentrant circuit is entirely within the compact AV node and that AV nodal tissue is present proximal and distal to the circuit. Recent evidence from mapping studies and from examination of the effects of curative procedures, however, suggests that the upper end of the circuit uses perinodal atrial or transitional tissue. Moreover, the anatomical substrate of dual "AV nodal" pathways is likely to be the multiple connections between compact AV node and atrium rather than discrete intranodal pathways. The antegrade slow pathway appears to be situated at the posteroinferior approaches to the AV node in the region between the coronary sinus orifice and the tricuspid annulus. The retrograde fast pathway appears to be situated in the anterior atrionodal connections at the apex of Koch's triangle, close to the His bundle. The lower turnaround point of the circuit is likely to be within the AV node.