This 48-year-old man has had frequent episodes of rapid palpitation since childhood, lasting 10-15 minutes, not associated with chest pain, dyspnea or faintness. He was investigated in a pediatric hospital and treated with medication until his teens, when he was lost to follow-up. He has had paroxysmal palpitation almost weekly. He is presenting to the Emergency Dept. because of a prolonged episode which started about one hour earlier. He is anxious and diaphoretic, otherwise he is free of dyspnea or weakness and is hemodynamically stable:

• Ventricular tachycardia, 145/min.
• AV dissociation with termination (capture beat) and reinitiation of VT
• Left bundle branch block pattern with inferior axis. Compatible with RVOT- VT (right ventricular outflow tract ventricular tachycardia)

The patient reverted spontaneously to sinus rhythm:

• Sinus rhythm with premature ventricular complexes in a pattern of bigeminy
• Left posterior fascicular block

Notice: the PVCs have the same QRS pattern as the VT of ECG #1. They most likely originate from the same area (right ventricular outflow tract)

The following ECG is recorded 7 1/2 hours after ECG 2:

• Sinus rhythm
• Left posterior fascicular block

Comments: After the investigation in the children hospital, a diagnosis of ventricular tachycardia with no evidence of structural heart disease was made and the patient was treated with propranolol until his teens when he dropped from follow up. There was no family history of sudden cardiac death. During the present admission, echocardiogram and cardiac MRI demonstrated normal structure and systolic function of both ventricles. The patient was started on metoprolol and the dosage was gradually titrated up to 100 mg. twice a day. There was no recurrence of arrhythmias. A diagnosis of idiopathic right outflow tract ventricular tachycardia (RVOTVT) was suggested   and electrophysiology studies and possible ablation were discussed with the patient, who opted for drug therapy. He will be closely followed.