Permanent junctional reciprocating tachycardia (Coumel tachycardia, PJRT)

Permanent junctional reciprocating tachycardia (Coumel tachycardia, PJRT)

Permanent junctional reciprocating tachycardia (Coumel tachycardia) is known in short as PJRT. It is an orthodromic atrioventricular reentrant tachycardia using a concealed accessory pathway with decremental properties as the retrograde limb. Most often it is a right posteroseptal accessory pathway. Though it can occur at all age groups, majority are seen in children and young adults. It is a long RP tachycardia with inverted P waves in inferior leads. As the tachycardia is incessant, there is a chance for development of tachycardiomyopathy. Catheter ablation can be achieved in PJRT with low complication rate [1]. But medical treatment is usually not that fruitful, though acute termination can be achieved, only to be followed by a recurrence.

It is named after  Coumel P et al, who described it in 1967 [2,3]. Pathological study by Critelli G et al showed that the accessory pathway was composed of ordinary myocardium joining the lower rim of the coronary sinus outlet to the uppermost ventricular muscle [3]. It had a sinuous, tortuous path and a changing cross-sectional area. This could explain the decremental characteristics similar to the atrioventricular node. Usual accessory pathways do not have decremental properties.

Usual slow-fast atrioventricular nodal re-entrant tachycardia initiated by an atrial ectopic beat has a sudden PR jump as the ectopic beat travels down the slow pathway. PJRT is also initiated by a critical shortening of atrial cycle length, but without the PR jump which is characteristic of typical slow-fast AVNRT. Though the involved posteroseptal pathway typically conducts only retrogradely, slow antegrade conduction has been documented after ablation of the His bundle [3].

Bilateral posteroseptal accessory pathways have been described in PJRT [4]. They found earliest activation in mid-septal region just above the coronary sinus ostium during right atrial mapping. Ablation at that site produced interruption of PJRT for three minutes. When the tachycardia resumed, there was no evidence of earlier right atrial activation. Successful ablation was then performed by retrograde aortic catheterization in the left posteroseptal region. Authors presumed that it could be either dual accessory pathways or a strand of the same broad left pathway which caused the early right atrial activation initially.

References

1. Kang KT, Potts JE, Radbill AE, La Page MJ, Papagiannis J, Garnreiter JM, Kubus P, Kantoch MJ, Von Bergen NH, Fournier A, Côté JM, Paul T, Anderson CC, Cannon BC, Miyake CY, Blaufox AD, Etheridge SP, Sanatani S. Permanent junctional reciprocating tachycardia in children: a multicenter experience. Heart Rhythm. 2014 Aug;11(8):1426-32. doi: 10.1016/j.hrthm.2014.04.033. Epub 2014 Apr 24. PMID: 24769425.
2. Coumel P, Cabrol C, Fabiato A, Gourgon R, Slama R. Tachycardie
   permanente par rhythme reciproque. Arch Mal Coeur 1967;60:1830-64. Cited in reference 2.
3. Critelli G, Gallagher JJ, Monda V, Coltorti F, Scherillo M, Rossi L. Anatomic and electrophysiologic substrate of the permanent form of junctional reciprocating tachycardia. J Am Coll Cardiol. 1984 Sep;4(3):601-10. doi: 10.1016/s0735-1097(84)80108-4. PMID: 6470342.
4. Mantovan R, Viani S, Stritoni P. Tachicardia reciprocante giunzionale permanente (tipo Coumel): un’inconsueta localizzazione della via accessoria retrograda [Permanent junctional reciprocating tachycardia (Coumel type): an unusual location of a retrograde accessory pathway]. G Ital Cardiol. 1999 Mar;29(3):315-20. Italian. PMID: 10231679.