BACKGROUND Dual atrioventricular (AV) node pathway physiology is frequently observed in patients with AV accessory pathways. RESULTS To examine the implications of this, we identified 36 patients (19 men and 17 women; mean +/- SD age, 30 +/- 13 years) with both phenomena. The 36 patients had 48 accessory pathways. Twenty-seven patients had bidirectional and 9 had unidirectional accessory pathways. Of the 34 patients with inducible atrioventricular reentry, 17 used the slow and 11 used the fast anterograde AV node pathway exclusively during AV reentrant tachycardia, whereas 6 patients used both the fast and the slow AV node pathways. AV node reentrant tachycardia was inducible in addition to AV reentry in 7 patients. Both the cycle length and AH intervals were significantly longer during slow pathway-dependent (cycle length, 411 +/- 58 milliseconds [ms]; AH, 229 +/- 42 ms) than during fast pathway-dependent (cycle length, 322 +/- 40 ms; AH, 121 +/- 25 ms; P < .05) reentrant tachycardias. Two patients had only AV node reentrant tachycardia inducible despite the presence of the accessory pathway. Four patients with technically difficult accessory pathways were managed by AV node modification with slow pathway (3) or fast pathway (1) ablation. Three of them remained free of symptoms 7, 14, and 25 months after the procedure whereas 1 patient had recurrence of arrhythmia. CONCLUSIONS AV reentrance with dual AV node pathways frequently depends exclusively on either the slow or the fast AV node pathway for clinical tachycardia. This may provide additional options for ablation in technically difficult cases when the accessory pathway is not otherwise problematic.