'The Turtle and the Hare'

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Author(s) A.A.M. Wilde, R.B.A. van den Brink
NHJ edition: 2005:4,156
These Rhythm Puzzles have been published in the Netherlands Heart Journal and are reproduced here under the prevailing creative commons license with permission from the publisher, Bohn Stafleu Van Loghum.
The ECG can be enlarged twice by clicking on the image and it's first enlargement
Figure 1
Figure 2

An otherwise healthy 32-year-old male was referred with palpitations. Attacks had been occurring monthly for several years, predominantly at the start of exercise (he is an enthusiastic sportsman), lasting minutes to days. Sotalol had been prescribed but almost immediately discontinued several months previously due to bradycardia. The patient was on no other drugs, and rejected further pharmacological treatment. Physical examination, stress-test and cardiac ultrasound were all normal. Atrial fibrillation (AF) had been documented repeatedly, and the patient was scheduled to undergo pulmonary vein (PV) isolation. Figure 1 shows his preablation ECG; figure 2 is typical of all postablation ECGs during the three months of follow-up.

What is the obvious difference, and how could you explain it?