ATRIAL DISSOCIATION IN A PATIENT S/P CARDIAC TRANSPLANT

This is from a pt with NICM, s/p cardiac transplant. 

If you look at long lead II, some of you might call this wandering atrial pacemaker or WAP because you are seeing variable P wave morphology. However, in the "real" WAP, the change in the P wave is gradual. The popular WAP which is described by most books as a pattern with at least 3 different P wave morphology should properly be called multifocal atrial rhythm or multifocal atrial tachycardia depending on the rate ( ≤100 or > 100 bpm, respectively). In this case, there are 2 P waves with the dominant P wave (red arrows) with a rate of ~88 bpm with small +/bigger - component. The second P wave (black arrows)  has a rate of ~50 bpm with a dominant + component. Sometimes there is fusion of the P waves (F) which creates confusion. Thus, this strip is showing ATRIAL DISSOCIATION IN A PATIENT S/P CARDIAC TRANSPLANT.