A narrow QRS tachycardia with eccentric atrial activation is presented with features favoring an orthodromic atrioventricular re-entrant tachycardia including an extranodal paraHisian response, and a short corrected post-pacing interval to tachycardia cycle length difference following right ventricular entrainment. However, during entrainment, the H-H interval was entrained by the pacing train several beats prior to the A-A interval which would suggest an atrioventricular nodal re-entry tachycardia. We discuss the diagnosis and its mechanism.
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