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Supernormal Conduction
Sergio L. Pinski, MD, FHRS
Medical University of South Carolina
Charleston, South Carolina, USA
@SergioPinski
• No conflicts of interest, besides the fact that I am Argentinian.
Definitions of Supernormal Conduction
A misnomer. Conduction is not better than normal.
”Impulse conduction is better than expected”
”Conduction that is better than anticipated under the circumstances”
“ Propagation succeeds early in diastole and fails later".
True only when conduction improves in relation to a supernormal phase
of excitability. Many other unrelated causes of improvement “pseudo-
supernormal conduction”
The case of Katz & Pick, 1956
1962
1968 1973
1983
The definitive review - Mandatory reading
for EP fellows
Current Cardiology Reviews, 2014, 10: 202-221
Latest edition of Josephson’s edited by
Callans
Causes of pseudo supernormal conduction
in AV conduction
• Gap phenomena
• Shortening of refractoriness by changing the preceding cycle length
• Peeling of refractoriness by an early beat
• Manifest or concealed nodal reentry during Wenckebach periodicity
• Dissociation with interference
• Dual AV nodal pathways
• Pulsatile changes in vagal discharge
• Facilitation of conduction by ectopic beats (summation)
Causes of pseudo supernormal conduction
in bundle branch block
• Gap phenomena
• Peeling of refractoriness by an early beat
• Shortening of refractoriness by changing the preceding cycle
length
• Dissipation of concealed transeptal conduction
• Wenckebach phenomenon in the bundle branches
• Bradycardia-dependent or phase 4 block
• Bilateral bundle branch delay
Equal delay in conduction in the bundle
branches: My pet peeve
• To my knowledge, never demonstrated. I could not find a convincing
example in a thorough literature review. I believe it unlikely to exist.
• Clinical and experimental evidence demonstrate that most cases of
bundle branch block are true “blocks”
• Given the very different length of the fascicles, the possibility that delay
will be exactly the necessary in each one to result in a narrow QRS is very
improbable
• Type 2 gap can result in pseudo supernormal conduction with a long HV.
Diligent search for a split His or a bundle branch potential reveals that
the delay is proximal.
Where does supernormal conduction exist?
• In depressed or injured His-Purkinje system (mainly bundle
branches)
• In not very healthy A-V accessory pathways (WPW)
• It cannot occur in the AV node. AV supernormal conduction
can only occur in infranodal block, and so it is a special
variant of supernormal conduction in His or bundle branches
Typical behavior of supernormal conduction
in intermittent bundle branch block
Rosenbaum et al. Cardiol Clin 1983;1:75
Supernormal conduction in LBB in presence
of RBBB= supernormal AV conduction
Miles & George. Cardiol Clin 2023;41:315
Unexpected narrow beats during atrial fibrillation
Wellens H. Am Heart J 1969;77:158
Spontaneous demonstration of
supernormal conduction in LBBB
Levi et al. In Frontiers in Cardiac Electrophysiology, 1983
PAC and compensatory pause unmasks phase 3
block and supernormal conduction in LBB
@SergioPinski
Marked sinus arrhythmia unmasks phase 3 block
and supernormal conduction in LBB
@SergioPinski
PACs with possible supernormal conduction in
the left anterior fascicle
@SergioPinski
Supernormal conduction as a mechanism
of 2:1 bundle branch block
Elizari et al. Curr Cardiol Rev 2014;202-221
1:1 Supernormal Conduction
Aldariz et al. Rev Arg Cardiol 1998;66:203
Supernormal Conduction explains early
captures in infranodal block
Rosenbaum et al. Cardiol Clin 1983;1:75
Supernomal conduction explains the
paradoxes of 3:2 Mobitz II AV block
Rosenbaum et al. Cardiol Clin 1983;1:75
Pacing proves that Mobitz II 3:2 is due to
supernormal conduction
@SergioPinski
Even the HV can shorten due to supernormal
conduction
Rosenbaum et al. Cardiol Clin 1983;1:75
Paradoxical shortening of the 2nd PR in 3:2
AV nodal block
Pinski et al. J Cardiovasc Electrophysiol 1996;7:1091
Paradoxical shortening of the PR in 3:2 AV
nodal block
Pinski et al. J Cardiovasc Electrophysiol 1996;7:1091
Supernormal conduction in WPW
Przybylski et al. Am J Cardiol 1987;9:1269
Supernormal conduction in WPW resulting in
2:1 pre-excitation
Cheng et al. Am J Cardiol 1987;59:852
Supernormal retrograde conduction in
left concealed accessory pathway
Chiale et al. J Cardiovasc Pharmacol Ther 2007;12:181
Possible 1:1 supernormal conduction in WPW
Chiale et al. J Cardiovasc Pharmacol Ther 2007;12:181
Conclusions
• Supernormal conduction exists in depressed His-Purkinje tissue
(generally intermittent bundle branch block) and AV accessory
pathways with poor conduction
• Generally, has little clinical significance but helps explain may puzzling
ECG findings.
• It can be casual to the rare cases of sudden death in patients with
WPW with a long baseline refractory period

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A thorough review of supernormal conduction.pptx

  • 1. Supernormal Conduction Sergio L. Pinski, MD, FHRS Medical University of South Carolina Charleston, South Carolina, USA @SergioPinski
  • 2. • No conflicts of interest, besides the fact that I am Argentinian.
  • 3. Definitions of Supernormal Conduction A misnomer. Conduction is not better than normal. ”Impulse conduction is better than expected” ”Conduction that is better than anticipated under the circumstances” “ Propagation succeeds early in diastole and fails later". True only when conduction improves in relation to a supernormal phase of excitability. Many other unrelated causes of improvement “pseudo- supernormal conduction”
  • 4. The case of Katz & Pick, 1956
  • 6. The definitive review - Mandatory reading for EP fellows Current Cardiology Reviews, 2014, 10: 202-221
  • 7. Latest edition of Josephson’s edited by Callans
  • 8.
  • 9. Causes of pseudo supernormal conduction in AV conduction • Gap phenomena • Shortening of refractoriness by changing the preceding cycle length • Peeling of refractoriness by an early beat • Manifest or concealed nodal reentry during Wenckebach periodicity • Dissociation with interference • Dual AV nodal pathways • Pulsatile changes in vagal discharge • Facilitation of conduction by ectopic beats (summation)
  • 10. Causes of pseudo supernormal conduction in bundle branch block • Gap phenomena • Peeling of refractoriness by an early beat • Shortening of refractoriness by changing the preceding cycle length • Dissipation of concealed transeptal conduction • Wenckebach phenomenon in the bundle branches • Bradycardia-dependent or phase 4 block • Bilateral bundle branch delay
  • 11. Equal delay in conduction in the bundle branches: My pet peeve • To my knowledge, never demonstrated. I could not find a convincing example in a thorough literature review. I believe it unlikely to exist. • Clinical and experimental evidence demonstrate that most cases of bundle branch block are true “blocks” • Given the very different length of the fascicles, the possibility that delay will be exactly the necessary in each one to result in a narrow QRS is very improbable • Type 2 gap can result in pseudo supernormal conduction with a long HV. Diligent search for a split His or a bundle branch potential reveals that the delay is proximal.
  • 12. Where does supernormal conduction exist? • In depressed or injured His-Purkinje system (mainly bundle branches) • In not very healthy A-V accessory pathways (WPW) • It cannot occur in the AV node. AV supernormal conduction can only occur in infranodal block, and so it is a special variant of supernormal conduction in His or bundle branches
  • 13. Typical behavior of supernormal conduction in intermittent bundle branch block Rosenbaum et al. Cardiol Clin 1983;1:75
  • 14. Supernormal conduction in LBB in presence of RBBB= supernormal AV conduction Miles & George. Cardiol Clin 2023;41:315
  • 15. Unexpected narrow beats during atrial fibrillation Wellens H. Am Heart J 1969;77:158
  • 16. Spontaneous demonstration of supernormal conduction in LBBB Levi et al. In Frontiers in Cardiac Electrophysiology, 1983
  • 17. PAC and compensatory pause unmasks phase 3 block and supernormal conduction in LBB @SergioPinski
  • 18. Marked sinus arrhythmia unmasks phase 3 block and supernormal conduction in LBB @SergioPinski
  • 19. PACs with possible supernormal conduction in the left anterior fascicle @SergioPinski
  • 20. Supernormal conduction as a mechanism of 2:1 bundle branch block Elizari et al. Curr Cardiol Rev 2014;202-221
  • 21. 1:1 Supernormal Conduction Aldariz et al. Rev Arg Cardiol 1998;66:203
  • 22. Supernormal Conduction explains early captures in infranodal block Rosenbaum et al. Cardiol Clin 1983;1:75
  • 23. Supernomal conduction explains the paradoxes of 3:2 Mobitz II AV block Rosenbaum et al. Cardiol Clin 1983;1:75
  • 24. Pacing proves that Mobitz II 3:2 is due to supernormal conduction @SergioPinski
  • 25. Even the HV can shorten due to supernormal conduction Rosenbaum et al. Cardiol Clin 1983;1:75
  • 26. Paradoxical shortening of the 2nd PR in 3:2 AV nodal block Pinski et al. J Cardiovasc Electrophysiol 1996;7:1091
  • 27. Paradoxical shortening of the PR in 3:2 AV nodal block Pinski et al. J Cardiovasc Electrophysiol 1996;7:1091
  • 28. Supernormal conduction in WPW Przybylski et al. Am J Cardiol 1987;9:1269
  • 29. Supernormal conduction in WPW resulting in 2:1 pre-excitation Cheng et al. Am J Cardiol 1987;59:852
  • 30. Supernormal retrograde conduction in left concealed accessory pathway Chiale et al. J Cardiovasc Pharmacol Ther 2007;12:181
  • 31. Possible 1:1 supernormal conduction in WPW Chiale et al. J Cardiovasc Pharmacol Ther 2007;12:181
  • 32. Conclusions • Supernormal conduction exists in depressed His-Purkinje tissue (generally intermittent bundle branch block) and AV accessory pathways with poor conduction • Generally, has little clinical significance but helps explain may puzzling ECG findings. • It can be casual to the rare cases of sudden death in patients with WPW with a long baseline refractory period