DESCRIPTIONA 30-year-old man presented with a 1-day history of sudden onset palpitations. He was haemodynamically stable. Twelve-lead electrocardiography showed wide complex tachycardia with right bundle branch block and left superior axis (figures 1 and 2). Every two wide complex beats were followed by a narrow complex beat and this cycle was repeating. Careful inspection revealed that narrow complex beats were having fixed relationship to wide complexes and among themselves, but there was atrioventricular (AV) dissociation. The patient's echocardiographic examination was normal. He was reverted to normal sinus rhythm with DC cardio V.150 Joules. Before direct current (DC) cardioversion, verapamil and β-blockers tried but not successful.These narrow complexes were capture beats 1 2 as they were same as sinus beats (in having a qR in V1) when the patient was in sinus rhythm after treatment (figure 3). Ventricular tachycardia (VT) localisation was idiopathic left ventricular VT from posterior fascicle, 3 but regularity of capture beats was the one point that made us doubt our diagnosis. The only explanation we can offer is that patient might be having dual AV node physiology or re-entry occurring at junction. The narrow complex beat may be conducting via the one pathway (interval between preceding wide QRS beat and narrow QRS beat is shorter than the interval between narrow QRS and following wide QRS beat best seen in V1) but at the same time the other site of the circuit is refractory, so re-entry abolishes and V happens with wide QRS. Again after two V's this cycle reappears. Response to DC shock

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DESCRIPTIONA 43-year-old man presented with effort angina Canadian cardiovascular society class III. The patient has been a chronic smoker and diabetic for 15 years. Cardiac examination and 12-lead ECG was normal. Echocardiogram revealed normal left ventricular ejection fraction with no regional wall motion abnormality. He was electively taken for coronary angiogram which revealed small calibre left circumflex (LCX) which was diminutive, diffusely diseased and subtotally occluded distally (figure 1; video 1). Left anterior descending artery (LAD; type II) had subtotal occlusion in mid segment (figure 2; video 2). Right coronary artery (RCA) was dominant with insignificant stenosis in proximal-to-mid RCA (figure 3; video 3). Posterior descending artery had ostioproximal severe disease (1.5 mm vessel) with moderate disease in distal segment (video 3). Posterior left ventricle (PLV) had mild disease (video 3). One branch from PLV was coursing above the origin of RCA (figure 3; video 3). This was a very lengthy branch with termination above the origin of RCA and appearing as wire around the heart. Initially we were confused about the name of this branch. After carefully reanalysing the angiogram, we concluded that it is the large left atrial branch originating from PLV (of RCA) in the presence of diminutive LCX.The patient underwent angioplasty with stenting to LAD and is doing well on follow-up.Sometimes we see things in the catheterisation laboratory which we have not seen previously in our life, like this large left atrial branch from PLV.To the best of our knowledge we are reporting for the first time, the origin of a large lengthy left atrial branch from PLV (of RCA). Significance of detailed knowledge of left atrial branches during catheter ablation for atrial fibrillation 1 has been stressed by earlier studies.Atrial branches of coronary arteries between the left atrial appendage and left superior pulmonary vein and the branches between left inferior pulmonary vein and mitral annulus can be problematic while atrial fibrillation ablation. Recurrence of atrial fibrillation can occur due to protected myocardium near atrial branches. Video 1 Right anterior oblique caudal view (left system) showing diminutive LCX with diffuse disease followed by subtotal distal occlusion.