Manifest and concealed reentry: a mechanism of A-V nodal Wenckebach in man.

In five patients, bundle of His electrograms were recorded during right ventricular pacing at various cycle lengths. In all patients, as the cycle length of stimulation was decreased, the pattern of retrograde conduction proceeded from 1:1 retrograde conduction to retrograde Wenckebach with or without manifest reentry, to retrograde Wenckebach cycles with concealed reentry. The requisite condition for reentry was a critical retrograde A-V nodal delay. During retrograde Wenckebach cycles, reentry could be either concealed or manifest. Concealed reentry resulted in typical or ordinary Wenckebach cycles on the surface electrocardiogram and manifest reentry resulted in ventricular echo beats. Depending upon the cycle length of stimulation, reentry could be concealed on the surface electrocardiogram but manifest on the His bundle electrogram recording. Concealed reentry could be manifest by turning off the stimulator at the appropriate time in the cardiac cycle while manifest reentry could be concealed by changing the cycle length of stimulation. Reentry with collision of wavefronts within the A-V node or proximal His-Purkinje conduction system explains why the last ventricular impulse is not conducted to the atria during ordinary Wenckebach cycles.