Sinoatrial Reentry Tachycardia: A Review

Simmers, TA and Sreeram, N (2003) Sinoatrial Reentry Tachycardia: A Review. [Journal (Paginated)]

Full text available as:



The concept of reentry within the sinus node is by no means new. In their 1943 report, Barker and co-workers postulated that “…a circus rhythm could be accommodated in auricular muscle and in one of the specialized nodes at known rates of conduction and with cycle lengths such as occur in paroxysmal tachycardia” 1. Lack of invasive electrophysiology at that time and subsequent failure to appreciate the heterogeneity of supraventricular arrhythmias, left their astute observation in the realm of conjecture. It was not until 1968 that Han, Malozzi and Moe finally demonstrated the existence of sinoatrial echoes 2. In a superfused isolated rabbit right atrial preparation, they examined the response to premature extrastimuli with an 18 electrode grid at the sinus node and surrounding atrial tissue. They found that critically timed extrastimuli led to early re-excitation of the atrium, supposedly due to sinoatrial reentry. Sequential microelectrode measurements of sinus node and atrial transmembrane potentials were performed in an attempt to provide a temporal and anatomical map of the observed phenomenon. Based on findings, the authors concluded that sinoatrial reciprocation was caused by entrance block at one site, slow conduction within the node with disparate refractoriness, and re-excitation of the atrium at the original area of entrance block. They went on to suggest that repetition of this phenomenon may conceivably form the basis for clinically relevant tachycardia. In vivo confirmation of sinoatrial echoes was inferred from work by Childers 3 and Paulay 4. In the former study, programmed electrical stimulation was performed in dogs. Three responses to premature atrial stimuli were noted: complete interpolation (i.e. the subsequent sinus complex was on time), incomplete interpolation (i.e. the subsequent beat was delayed), and sinus echo. In the latter, the first post-extrastimulus complex was electrocardiographically the same as sinus, but earlier than expected. The authors attributed this to sinoatrial reentry, and went on to describe each of the three responses to premature atrial beats in a 70-year-old man in an elegant electrocardiographic deduction of underlying mechanisms. An in vivo canine model was also employed in the report by Paulay et al. While confirming Childers’ findings, Paulay offered two additional pieces of evidence implicating the sinus node/perinodal area: firstly, timing of the echo was independent of stimulation site (they performed pacing at the sinus node, Bachmann’s bundle, right and left atrial appendages and low atrial septum), and secondly echoes were eliminated by crushing the sinus node. As has long been the case for AV nodal reentry tachycardia, it is apparent that considerable discussion also revolves around the issue of whether sinoatrial echoes do or do not involve perinodal atrial tissue as well as the sinus node itself. In 1979, Allessie and Bonke published work suggesting confinement of the re-entrant circuit to the node per se 5. The experimental set-up was similar to earlier work by Han 2, with the significant difference that resolution of the measuring electrodes was superior: 32 unipolar surface atrial electrograms were recorded during initiation of sinoatrial echoes as opposed to the 18 used by Han. In addition, up to 130 transmembrane sinus node potentials were recorded sequentially in cases of sustained reciprocation. These detailed observations led to the conclusion that sinus node reentry was confined to a circuitous pathway in an extremely small area (1-2mm) with low conduction velocities (2.5cm/s) within the node itself. It is of note that the same authors pointed out the inability to induce sustained arrhythmia in this model, and later concluded that sinoatrial reentry tachycardia (SART) may not be feasible without border zone atrial tissue. Given the limitations inherent to in vivo study in man, it may be fair to continue to use “sinus node reentry” and “sinoatrial reentry” synonymously for the time being. In the wake of in vivo studies in dogs, and reports of sinus node reentry in man by Paulay 6 and Childers 3, Narula first described sustained SART in two patients in 1974 7. Out of 300 patients undergoing electrophysiologic study, he observed sinus node reentry beats in 20, and sustained tachycardia in two. The criteria for the diagnosis of SART proposed by Narula are still valid: 1. atrial activation and P-wave morphology are the same or highly similar to sinus rhythm, with activation from high to low right atrium, 2. the arrhythmia is inducible with atrial extrastimuli at specific coupling intervals, independent of AV nodal conduction intervals and site of stimulation, and 3. the arrhythmia can be terminated by atrial stimuli. SART is thus, by definition, a paroxysmal arrhythmia.

Item Type:Journal (Paginated)
Keywords:Sinoatrial Reentry Tachycardia
Subjects:JOURNALS > Indian Pacing and Electrophysiology Journal
ID Code:4259
Deposited By:Indian Pacing and Electrophysiology, Journal
Deposited On:24 Apr 2005
Last Modified:11 Mar 2011 08:55

References in Article

Select the SEEK icon to attempt to find the referenced article. If it does not appear to be in cogprints you will be forwarded to the paracite service. Poorly formated references will probably not work.

1. Barker PS, Wilson FN, Johnston FD. The mechanism of auricular paroxysmal tachycardia. Am Heart J 1943;26:435-445

2. Han J, Malozzi AM, Moe GK. Sino-atrial reciprocation in the isolated rabbit heart. Circ Res 1968;22:355-362

3. Childers RW, Arnsdorf MF, de la Fuente DJ, Gambetta M, Svenson R. Sinus nodal echoes. Clinical case report and canine studies. Am J Cardiol 1973;31:220-231

4. Paulay KL, Varghese J, Damato AN. Sinus node reentry. An in vivo demonstration in the dog. Circ Res 1973;32:455-463

5. Allessie MA, Bonke FIM. Direct demonstration of sinus node reentry in the rabbit heart. Circ Res 1979;44:557-568

6. Paulay KL, Varghese PJ, Damato AN. Atrial rhythms in response to an early premature atrial depolarization in man. Am Heart J 1973;85:323-331

7. Narula OS. Sinus node re-entry. A mechanism for supraventricular tachycardia. Circulation 1974;50:1114-1128

8. Cossú SF, Steinberg JS. Supraventricular tachyarrhythmias involving the sinus node: clinical and electrophysiologic characteristics. Progr Cardiovasc Dis 1998;41:51-63

9. Wu D, Denes P, Amat-y-Leon F, Dhingra R, Wyndham CRC, Bauernfeind R, Latif P, Rosen KM. Clinical, electrocardiographic and electrophysiologic observations in patients with paroxysmal supraventricular tachycardia. Am J Cardiol 1978;41:1045-1051

10. Gomes JA, Hariman RJ, Kang PS, Chowdry IH. Sustained symptomatic sinus node reentrant tachycardia: incidence, clinical significance, electrophysiologic observations and the effects of antiarrhythmic agents. J Am Coll Cardiol 1985;5:45-57

11. Gomes JA, Mehta D, Langan MN. Sinus node reentrant tachycardia. PACE 1995;18:1045-1057

12. Wellens HJ. Role of sinus node reentry in the genesis of sustained cardiac arrhythmias. In: Bonke FIM, ed. The sinus node: structure, function and clinical relevance. The Hague, Boston, London: Martinus Nijhoff, 1978:422-427

13. Weisfogel GM, Batsford WP, Paulay KL, Josephson ME, Ogunkelu JB, Akhtar M, Seides SF, Damato AN. Sinus node re-entrant tachycardia in man. Am Heart J 1975;90:295-30

14. Kay GN, Chong F, Epstein AE, Dailey SM, Plumb VJ. Radiofrequency ablation for the treatment of primary atrial tachycardias. J Am Coll Cardiol 1993;21:901-909

15. Sperry RE, Ellenbogen KA, Wood MA, Belz MK, Stambler BS. Radiofrequency catheter ablation of sinus node re-entrant tachycardia. PACE 1993;16:2202-2209

16. Lesh MD, Van Hare GF, Epstein LM, Fitzpatrick AP, Scheinman MM, Lee RJ, Kwasman MA, Grogin HR, Griffin JC. Radiofrequency catheter ablation of atrial arrhythmias. Results and mechanisms. Circulation 1994;89:1074-1089

17. Pahlajani DB, Miller RA, Serratto M. Sinus node re-entry and sinus node tachycardia. Am Heart J 1975;90:305-311

18. Gillette PC. The mechanisms of supraventricular tachycardia in children. Circulation 1976;54:133-139

19. Garson A, Gillette PC. Electrophysiologic studies of supraventricular tachycardia in children. Am Heart J 1981;102:233-250

20. Blaufox AD, Numan M, Knick B, Saul JP. Sinoatrial node re-entrant tachycardia in infants with congenital heart disease. Am J Cardiol 2001;88:1050-1054

21. Yee R, Guiraudon GM, Gardner MJ, Gulamhusein SS, Klein GJ. Refractory paroxysmal sinus tachycardia: management by subtotal right atrial exclusion. J Am Coll Cardiol 1984;3:400-404

22. Mischke K, Stellbrink C, Hanrath P. Evidence of sinoatrial block as a curative mechanism in radiofrequency current ablation of inappropriate sinus tachycardia. J Cardiovasc Electrophysiol 2001;12:264-267

23. Simmers TA, Wittkampf FHM, Derksen R. Isolation of residual sinus node during catheter ablation for the treatment of inappropriate sinus tachycardia. Neth Heart J 2002;10:517-519

24. Hendry PJ, Packer DL, Anstadt MP, Plunkett MD, Lowe JE. Surgical treatment of automatic atrial tachycardias. Ann Thorac Surg 1990;49:253-260

25. Kerr CR, Klein GG, Guiraudon GM, Webb JG. Surgical therapy for sinoatrial re-entrant tachycardia. PACE 1988;11:776-783

26. Poty H, Saoudi N, Haïssaguerre M, Daou A, Clémenty J, Letac B. Radiofrequency catheter ablation of atrial tachycardias. Am Heart J 1996;131:481-489.

27. Farré J, Grande A, Martinell A. Atrial unipolar waveform analysis during retrograde conduction over left-sided accessory atrioventricular pathways. In Brugada P, Wellens HJJ eds: Cardiac arrhythmias: where to go from here? Futura publishing co., Mount Kisco, NY, 1987:243-269

28. Haïssaguerre M, Dartigues JF, Warin JF, Le Metayer P, Montserrat P, Salamon R. Electrogram patterns predictive of successful catheter ablation of accessory pathways. Value of unipolar recording mode. Circulation 1991;84:188-202

29. Simmers TA, Hauer RNW, Wever EFD, Wittkampf FHM, Robles de Medina EO. Unipolar electrogram models for prediction of outcome in radiofrequency ablation of accessory pathways. PACE 1994;17:186-198

30. Delacretaz E, Soejima K, Gottipaty VK, Brunckhorst CB, Friedman PL, Stevenson WG. Single catheter determination of local electrogram prematurity using simultaneous unipolar and bipolar recordings to replace the surface ECG as a timing reference. PACE 2001;24:441-449

31. Villacastin J, Almendral J, Arenal A, Castellano NP, Gonzalez s, Ortiz M, García J, Vallbona B, Moreno J, Portales JF, Torrecilla EG. Usefulness of unipolar electrograms to detect isthmus block after radiofrequency ablation of typical atrial flutter. Circulation 2000;102:3080-3085

32. Man KC, Daoud EG, Knight BP, Bahu M, Weiss R, Zivin A, Souza SJ, Goyal R, Strickberger SA, Morady F. Accuracy of the unipolar electrogram for identification of the site of origin of ventricular activation. J Cardiovasc Electrophysiol 1997;8:974-979

33. Tada H, Oral H, Knight BP, Ozaydin M, Chugh A, Scharf C, Hassan S, Greenstein R, Pelosi F, Strickberger SA, Morady F. Randomized comparison of bipolar versus unipolar plus bipolar recordings during segmental ostial ablation of pulmonary veins. J Cardiovas Electrophysiol 2002;13:851-856

34.. Sanders WE, Sorrentino RA, Greenfield RA, Shenasa H, Hamer ME, Wharton JM. Catheter ablation of sinoatrial node reentrant tachycardia. J Am Coll Cardiol 1994;23:926-934

35. Ivanov MY, Evdokimov VP, Vlasenco VV. Predictors of successful radiofrequency catheter ablation of sinoatrial tachycardia. PACE 1998;21:311-315

36. Simmers T, Sreeram N, Wittkampf F. Catheter ablation of sinoatrial reentry tachycardia in a 2-month-old infant. Heart 2003;89:e1

37. Leonelli FM, Pisanó E, Requarth JA, Potenza D, Tomassoni G, Oçonnor W, Natale A. Frequency of superior vena cava syndrome following radiofrequency modification of the sinus node and its management. Am J Cardiol 2000;85:771-774


Repository Staff Only: item control page