A 25 year old woman is referred to the electrophysiology clinic for frequent long episodes of palpitations for a few years. Her echocardiogram shows LVEF of 45% with global hypokinesis. Her ECG is shown below: 

• Supraventricular tachycardia likely Permanent Junctional Reciprocating Tachycardia (PJRT), ventricular rate 123/min 

Comment: Permanent Junctional Reciprocating Tachycardia (PJRT) is a type of supraventricular tachycardia causing Atrioventricular reentrant tachycardia that is characterized by negative P wave axis in inferior leads (annotated as Ps) and long RP interval. Unlike typical accessory pathways, PJRT accessory pathways exhibit decremental conduction, and thus retrograde conduction is delayed resulting in a long RP interval. Due to the incessant characteristics of PJRT, it can occasionally lead to tachycardia-induced cardiomyopathy.  

Below is her ECG after ablation of accessory pathway:

• Normal sinus rhythm, ventricular rate 71/min