ECG phenomena: alternating QRS morphologies | Heart

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ECG phenomena: alternating QRS morphologies

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Dual atrioventricular nodes
Robert H. Anderson
Published on: 23 November 2015

Published on: 23 November 2015
Dual atrioventricular nodes
- Robert H. Anderson, Retired
I read with great interest the "challenge" posed by the electrocardiographic recording in issue 7 of Heart for 2014. I also noted with interest that the authors suggest that Monckeberg provided the first account of such dual nodes in 1993 (their reference #1). Since Monckeberg was long since dead by that date, this must be some mistake! I think the appropriate date is 1913. It is certainly the case that Monckeberg was th...
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I read with great interest the "challenge" posed by the electrocardiographic recording in issue 7 of Heart for 2014. I also noted with interest that the authors suggest that Monckeberg provided the first account of such dual nodes in 1993 (their reference #1). Since Monckeberg was long since dead by that date, this must be some mistake! I think the appropriate date is 1913. It is certainly the case that Monckeberg was the first to describe this rare anatomic arrangement. Monckeberg's heart, however, was characterised by the presence of discordant atrioventricular connections, and double outlet right ventricle. Since then, dual atrioventricular nodes have been demonstrated in another heart with double outlet right ventricle, but in the setting of concordant atrioventricular connections (Br Heart J 1973; 35: 566-569). To the best of my knowledge, all other hearts subsequently published with dual atrioventricular nodes have either had isomerism of the atrial appendages (Smith et al, Cardiol Young 2006; 16: 437-454), or else discordant atrioventricular connections, as in the index case described by Monckeberg. Again, to the best of my knowledge, hearts have yet to be described with dual nodes located as shown in the cartoon provided by Paech and colleagues. It is possible that their patient, with hypoplastic left heart syndrome, could have had a so- called "atriofascicular tract", since that is the closest arrangement of which I am aware that fits their cartoon.The second node in these situations, however, is found anterolaterally within the right atrioventricular junction (Becker et al, Circulation 1978; 57: 870-879), rather than inferiorly as pictured in their cartoon. I wonder, therefore, what additional information they have to prove that their patient had dual atrioventricular nodes? On the basis of my own experience with assessing autopsied hearts, I would be very surprised to find the arrangement that they have depicted in a patient with hypoplastic left heart syndrome.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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