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27-10-2017 | Rhythm Puzzle - Answer | Uitgave 2/2018 Open Access

Netherlands Heart Journal 2/2018

An irregular atrial tachycardia

What is the underlying mechanism?

Netherlands Heart Journal > Uitgave 2/2018
S. Pagano, G. Aguglia, D. Noto, M. Averna


There are clearly visible P-waves in most of the leads (Fig.  1). The P-waves are negative in leads DII, DIII and aVF. Hence, this is not a sinus rhythm. All the P-waves have the same morphology, constant PP interval at a rate of 210 beats per minute (bpm), with an isoelectric baseline between them. Therefore, the underlying rhythm is unifocal atrial tachycardia [ 1].
Lead DII shows 12  P-waves, but some of these waves are barely discernible because they are superimposed on the QRS-T complexes (Fig.  2). In the first part of the strip there are P-waves alternately conducted and non-conducted to the ventricles, characterising a 2:1 AV conduction. In the middle half of the strip there is a longer RR interval where only the ninth P-wave conducts to the ventricles, while the seventh, eighth and tenth P-waves are blocked, realising a 4:1 AV conduction. So, the atrial tachycardia presents an alternating 2:1 and 4:1 AV conduction. The long RR interval is less than twice the short RR intervals and the PR intervals progressively lengthen until a pause with 3 non-conducted P-waves occurs. These elements are consistent with alternating Wenckebach periodicity, a rare phenomenon characterised by a block in two levels of the atrioventricular node; one proximally, giving rise to a 2:1 block and one distally, responsible for the Wenckebach periodicity that explains the progressive PR lengthening until the non-conducted P-wave [ 2]. Alternating Wenckebach periodicity is encountered primarily in atrial tachyarrhythmias; the most frequent block level is the atrioventricular node, but it has been described in almost every level of the conduction pathways, including accessory ones [ 3].
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

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Rhythm Puzzle - Question

An irregular atrial tachycardia