Wide complex irregularly regular tachycardia with QRS alternation

A 44-year-old white man was referred to our service because of a history of symptomatic rapid palpitations that had begun on January 2007. He had no previous history of syncope or family history of sudden cardiac death. The patient was otherwise well and had not been taking any medications. The electrocardiogram (ECG) recorded during sinus rhythm was within normal limits. A 12-lead ECG was performed during the last episode on July 2007 while he was working at his office. An irregular wide complex tachycardia with varying QRS morphology (left bundle-branch block with an alternating pattern) was documented. The differential diagnoses based on the 12-lead electrocardiogram (ECG) were supraventricular tachycardia with aberrant conduction and QRS alternans, atrial tachycardia with anterograde conduction over an accessory pathway, or ventricular tachycardia. An electrophysiology study was performed and the results are discussed.