Mobitz II AV block within the His bundle, with progression to complete heart block

A case of a 48-year-old woman with frequent syncopal episodes is reported. The electrocardiogram showed high degree AV block with narrow QRS complexes. The His bundle electrogram displayed a split His deflection indicating impairment of conduction within the His bundle of the Mobitz II type. The AH interval was prolonged and Wenckebach phenomenon occurred at the same atrial pacing rate before and after atropine administration. During spontaneous or induced high grade AV block an escape rhythm originating in the distal His bundle was observed. A secondary study performed one year later showed progression to complete AV block. Both His potentials were present, one following the atrial and the other preceding the ventricular deflection. The H'V interval was prolonged and a further lengthening was seen after ajmaline. All these findings indicated proximal, mid, and distal disease of the His trunk.