Looks Like VT But Isn't - Successful Ablation Of A Left Free Wall Accessory Pathway With Mahaim-like Properties

It was long believed that Mahaim pathways represented nodo-fascicular or nodo-ventricular connections. However, this misconception was challenged when patients underwent surgical or catheter ablation of the AV node but remained pre-excited. Electrophysiology (EP) studies showed these pathways to be right sided decrementally conducting atrio-fascicular accessory pathways with the atrium forming a part of the antidromic tachycardia circuit. Mahaim pathways are usually reported to occur on the right side. We report a patient who presented with a broad complex tachycardia thought to be ventricular tachycardia; however during EP study this was shown to be an antidromic atrioventricular tachycardia utilising a left free wall pathway that demonstrated 'Mahaim-like' properties and was successfully ablated. The pathway was shown to have long conduction times with no retrograde conduction, had an effective refractory period longer than the AV node and its conduction was only evident during antidromic AVRT. It also had a decremental antegrade property and was responsive to intravenous adenosine. These 'Mahaim-like' features are very unusual and rarely reported on the left side.