HANDS-ON
Para-Hisian pacing: Useful clinical technique to
differentiate retrograde conduction between accessory
atrioventricular pathways and atrioventricular nodal
pathways
Hiroshi Nakagawa, MD, PhD, and Warren M. Jackman, MD
From the Cardiac Arrhythmia Research Institute, Department of Medicine University of Oklahoma Health Sciences
Center, Oklahoma City, Oklahoma.
Para-Hisian pacing is a useful tool to differentiate be-
tween retrograde conduction over an accessory pathway and
retrograde conduction over the fast or slow atrioventricular
(AV) nodal pathways.1-3 Para-Hisian pacing uses right ven-
tricular (RV) pacing close to the His bundle or proximal
right bundle branch (RBB). As the position of the ventric-
ular pacing catheter changes subtly during respiration (or by
changing pacing output), the pacing stimulus changes cap-
ture among (1) basal anteroseptal RV plus His bundle or
proximal RBB (His bundle-RBB capture); (2) capture of
basal anteroseptal RV alone; and (3) His bundle-RBB cap-
ture alone. These changes in pacing capture result in abrupt
changes in the timing of His bundle activation relative to the
timing of ventricular activation. The presence or absence of
a change in atrial activation sequence, stimulus-atrial (SA)
intervals, and His bundle-atrial (HA) interval identifies
whether retrograde conduction is dependent on ventricular
activation (retrograde conduction over an accessory path-
way) or His bundle activation (retrograde conduction over
the AV node) or both (accessory pathway and AV node;
Figures 1 and 2). The loss of His bundle-RBB capture is
usually identified by the widening of the QRS complex,
indicating that some of the ventricular myocardium (farthest
from the RV basal septal pacing site) is activated by the
His-Purkinje system during both RV and His bundle-RBB
capture.
Our preferred approach is to position the RV pacing
catheter toward the RV outflow tract, 1–2 cm superior to the
His bundle catheter. While pacing at moderate output (5–10
mA and 2 ms pulse width), the RV catheter is slowly
withdrawn toward the His bundle catheter (proximal RBB)
until intermittent His bundle-RBB capture occurs because
of changes in catheter position during respiration. As the
Address reprint requests and correspondence: Hiroshi Nakagawa,
MD, PhD, Cardiac Arrhythmia Research Institute, University of Oklahoma
Health Sciences Center, 1200 Everett Drive (TUH-6E-103), Oklahoma
City, OK 73104.
E-mail address: hiroshi-nakagawa@ouhsc.edu.
1547-5271/$ -see front matter © 2005 Heart Rhythm Society. All rights reserved.
pacing catheter is moved closer to the His bundle, the
ventricular potential in the His bundle electrogram becomes
earlier and the retrograde His bundle potential becomes
later, providing greater separation between the local ven-
tricular and His bundle potentials. The use of closely spaced
electrodes (1 mm edge-to-edge) on the His bundle catheter
shortens the duration of the local ventricular potential in the
His bundle electrogram, preventing the masking of the His
bundle potential by the local ventricular potential. Closely
spaced electrodes on the pacing catheter may provide a
smaller pacing field, facilitating intermittent loss of His
bundle-RBB capture with small changes in catheter position
during respiration. A deflectable RV pacing catheter is po-
sitioned more easily for para-Hisian pacing and subsequent
positioning of the pacing catheter close to the location of an
accessory pathway (Figure 3A). In patients with proximal
RBB block (such as resulting from previous ablation), His
bundle-RBB capture requires pacing proximal to the RBB
block site and may not be achieved from the RV. Other
approaches include changing pacing output to achieve in-
termittent His bundle-RBB capture and use of the distal
electrodes on the His bundle catheter for pacing.4
Intermittent His bundle-RBB capture
Pattern 1 (Figure 2)
During para-Hisian pacing with continued RV capture,
the loss of His bundle-RBB capture with no change in
retrograde atrial activation sequence, no change in the SA
interval (any electrogram), and a shorter HA interval
indicate that retrograde conduction is dependent on ven-
tricular activation and not His bundle activation, that is,
conduction occurring over a single accessory pathway
(Figures 2 and 3). However, this does not exclude the
presence of retrograde conduction over the AV node with
doi:10.1016/j.hrthm.2005.01.026
668 Heart Rhythm, Vol 2, No 6, June 2005

Figure 1 Schematic representation of response to para-Hisian pacing between conduction over the AV node alone (A), conduction over
an accessory pathway alone (B), and conduction over the AV node and accessory pathway combined (C).

Figure 2 Algorithm for interpretation of the response to para-Hisian pacing (see text for explanation).
Nakagawa and Jackman Para-Hisian Pacing 669

Figure 3 Para-Hisian pacing in a

patient with a concealed anteroseptal
accessory pathway. A, B: Radio-
graphs in the right anterior oblique
(A) and left anterior oblique (B) pro-
jections, showing the positions of
electrode catheters. His bundle: de-
flectable octapolar electrode catheter
(1-mm spacing) positioned to record
His bundle potential from the distal
pairs of electrodes. RVPH: deflectable
quadripolar electrode catheter (1-mm
spacing) positioned for basal septal
RV pacing with intermittent capture
of proximal RBB (His bundle-RBB
capture). Other catheters are posi-
tioned at the right atrial (RA) append-
age, CS, and posteroseptal tricuspid
annulus. C: Electrograms recorded
during sinus rhythm. D: Electrograms
recorded during para-Hisian pacing.
The loss of His bundle-RBB capture
(right complex) is identified by delay
in His bundle activation (SH 60 ms)
and widening of QRS complex. The
SA intervals and retrograde atrial ac-
tivation sequence are unchanged, in-
dicating retrograde conduction over a
single accessory pathway (pattern 1 in
Figure 2).

longer conduction time (even during His bundle-RBB
capture; Figure 4) or a second accessory pathway with
either longer conduction time or located far from the
pacing site.3
In patients with both concealed anteroseptal accessory
pathway and retrograde fast AV nodal pathway conduction,
ventricular pacing at this site without His bundle-RBB cap-
ture allows selective retrograde conduction over the acces-
sory pathway for mapping (Figures 3D and 4A). In patients
with a posteroseptal accessory pathway, the delay in retro-
grade His bundle activation during ventricular pacing at this
site without His bundle-RBB capture may be sufficient for
mapping selective retrograde accessory pathway conduction
(Figure 5). In patients where retrograde AV nodal conduc-
tion masks retrograde posteroseptal accessory pathway con-
duction, positioning the ventricular pacing catheter close to
the posteroseptal tricuspid annulus (or proximal branches of
the coronary sinus [CS]) provides selective retrograde ac-
cessory pathway conduction for mapping. In contrast, ven-
tricular pacing from the RV apex (close to the Purkinje-
myocardial junction and far from the accessory pathway)
often results in selective retrograde AV nodal conduction or
fusion of AV nodal and accessory pathway conduction.
Patterns 2 and 3
The loss of His bundle-RBB capture with no change in
retrograde atrial activation sequence and an increase in
the SA interval can indicate retrograde conduction over
either an accessory pathway or the AV node. If there is a
670
Figure 4 Para-Hisian pacing in another patient with a con-
cealed anteroseptal accessory pathway. A: Before ablation, the
loss of His bundle-RBB capture in the right complex (SH 60 ms
and wider QRS) resulted in the same atrial activation sequence,
but with a 5-ms increase in SA interval (30 to 35 ms) due to a
5-ms increase in the stimulus-ventricular (SV) interval (10 to 15
ms) at the site of earliest atrial activation (pattern 2 in Figure 2).
B: After ablation, the SA interval was longer but retrograde
atrial activation was early in the His bundle electrograms sim-
ilar to before ablation. Without His bundle-RBB capture (left
complex), the SH interval was 65 ms. With His bundle-RBB
capture (right complex), the SH interval shortened by 50 ms (65
to 15ms). The SA intervals also shortened by 50 ms (185 to 135
ms and 200 to 150 ms) with no change in atrial activation
sequence, indicating retrograde conduction over the AV node
(pattern 3 in Figure 2).
similar increase in the local VA interval near the site of
earliest atrial activation and the HA interval shortens,
retrograde conduction is occurring over a single acces-
sory pathway (pattern 2; Figure 4A). As in pattern 1, this
response does not exclude the presence of retrograde
conduction over the AV node or a second accessory
pathway.
If the increase in the SA interval is associated with a
similar increase in the SH interval with little or no change in
Heart Rhythm, Vol 2, No 6, June 2005
the HA interval, retrograde conduction is occurring over the
AV node (pattern 3; Figure 4B).
Para-Hisian pacing may be the only technique to distin-
guish between retrograde accessory pathway and slow AV
nodal pathway conduction during or after ablation of an
epicardial posteroseptal accessory pathway due to the nearly
identical retrograde atrial activation sequences (Figure 5).
Both use the CS myocardium, with early activation of the
floor of the proximal CS and connection with the left atrium
2– 4 cm from the CS ostium (Figures 5D and 5E).
Patterns 4 and 5
Change in atrial activation sequence with loss of His bun-
dle-RBB capture indicates that retrograde conduction is
occurring over (1) an accessory pathway and the AV node;
(2) two or more accessory pathways; or (3) fast and slow
AV nodal pathways. If the increase in the SH interval is
similar to the increase in SA interval in the His bundle
electrogram, with little or no change in the HA interval,
retrograde conduction is occurring over the AV node and an
accessory pathway (Figures 2 and 6). Without recording
electrograms near the accessory pathway, the change in the
atrial activation sequence may not be identified, incorrectly
suggesting that retrograde conduction is occurring over just
the AV node (Figure 6). This is most likely to occur in
patients with a short retrograde AV nodal conduction time
(short HA interval) and an accessory pathway located far
from the pacing site (i.e., left free-wall accessory pathway).3
If the HA interval shortens, the presence of two or more
accessory pathways can be differentiated by moving the
ventricular pacing catheter close to each of the sites of early
retrograde atrial activation. Pacing at these sites should
facilitate selective conduction over each of the accessory
pathways (short local VA interval and minimum fusion in
atrial activation sequence).
Fusion of retrograde conduction over the fast and slow
AV nodal pathways usually occurs within a very limited
range of ventricular pacing cycle length (CL). Change in
atrial activation sequence with loss of His bundle-RBB
capture results from the lengthening of the HH interval.
Para-Hisian pacing can often be performed at a long CL
(fast pathway) and a short CL (slow pathway), confirming
that each pathway is dependent on His bundle activation.
Intermittent ventricular capture
Pattern 6
During para-Hisian pacing with continued His bundle-RBB
capture, the loss of ventricular capture with no change in
retrograde atrial activation sequence, SA interval, or HA
interval indicates that retrograde conduction is dependent on
His bundle activation and not ventricular activation, that is,
conduction occurring over the AN node.
Nakagawa and Jackman Para-Hisian Pacing 671

Figure 5 Para-Hisian pacing in a patient with a permanent form of junctional reciprocating tachycardia (PJRT) resulting from an
epicardial posteroseptal accessory pathway with long conduction time. A: Before ablation, the loss of His bundle-RBB capture
resulted in a marked increase in the SH interval to 175 ms and a 10-ms decrease in SA intervals with identical atrial activation
sequence, indicating retrograde conduction over a single accessory pathway with long conduction time (pattern 1 in Figure 2). The
10-ms decrease in the SA interval resulted from a 10-ms decrease in the SV interval close to the site of the accessory pathway (65
to 55 ms). B: Orthodromic AV reentrant junctional reciprocating tachycardia with a CL 425 ms. C: After ablation in the orifice of
the middle cardiac vein (cryoablation due to close proximity to the distal right coronary artery), ventricular pacing continued to
produce ventriculoatrial conduction with the same atrial activation sequence as the tachycardia. However, the loss of His bundle-RBB
capture now resulted in a 45-ms increase in SA intervals, similar to the 45-ms increase in S-RBB and SH intervals, with no change
in atrial activation sequence. This response (pattern 3 in Figure 2) indicates retrograde conduction over the slow AV nodal pathway
with the same atrial activation sequence as the accessory pathway. D: Schematic representation of retrograde conduction over the
epicardial posteroseptal accessory pathway. During tachycardia, the LV activates the CS myocardial extension along the middle
cardiac vein, followed by activation of the floor of the proximal CS. The CS myocardium activates the left atrium, 2– 4 cm from the
CS ostium. E: Retrograde conduction over the slow AV nodal pathway (rightward posterior extension) activates the floor of the CS
ostium. The CS myocardium activates the left atrium, 2– 4 cm from the CS ostium, producing the same retrograde atrial activation
sequence as the epicardial posteroseptal accessory pathway.

Pattern 7 Patterns 8 and 9

In patients with retrograde conduction over only a single
accessory pathway, the loss of ventricular capture results in
an increase in the SA interval (and HA interval), with little
or no change in the local VA interval near the site of earliest
atrial activation.
When loss of ventricular capture is associated with a change in
retrograde atrial activation sequence with little or no change in
the HA interval, retrograde conduction is occurring over the
AV node and an accessory pathway. If the HA interval length-
ens with the change in retrograde atrial activation sequence,
672
Figure 6 Para-Hisian pacing in a patient with a concealed left
posterior accessory pathway. The loss of His bundle-RBB cap-
ture results in an SH interval of 85 ms with an 80-ms increase
in the SA interval in the His bundle (50 to 130 ms) and right
atrial appendage RAA (85 to 165 ms) electrograms, consistent
with retrograde AV nodal conduction (fast pathway). However,
CS electrograms show a change in atrial activation sequence
with smaller increases in SA intervals (65 to 125 ms, 75 to 120
ms, and 85 to 125 ms), indicating retrograde accessory pathway
conduction as well as AV nodal conduction (pattern 4 in Fig-
ure 2).
Heart Rhythm, Vol 2, No 6, June 2005
retrograde conduction may be occurring over the AV node and
an accessory pathway or over two or more accessory path-
ways. These two options can often be differentiated by obtain-
ing ventricular capture with and without His bundle-RBB cap-
ture (retrograde AV nodal conduction will be delayed by the
loss of His bundle-RBB capture) or by pacing close to each of
the sites of early retrograde atrial activation as described.
References
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