This is a patient with a very long intraventricular delay. He is paced in both the atrium and the ventricle. The amount of the intraventricular block has increased over the years. In lead one we can see a ventricular pacing spike which is proceeded by a negative P wave (this is actually a paced P wave but the pacing spike can not be seen in this EKG) . Following after the first part of the QRS is a second component about 600ms later! The patient an elderly man who has complete heart block and ventricular tachycardia. He is presently stable on amiodarone, and has a dual chambe pacer/defibrillator.