Return of normal conduction after paroxysmal heart block. Report of a case with major discordance of electrophysiological and pathological findings

This report describes a 52 yr old male with paroxysmal heart block as well as left and right bundle branch block, resulting in Stokes Adams attacks. The patient experienced a return to 1:1 atrioventricular (A V) conduction with narrow QRS within 48 hr of the attacks and heart block never recurred. Electrophysiological studies 2 wk later revealed a narrow QRS, a normal H V interval (36 msec), 1:1 A V conduction up to an atrial paced rate of 210 beats/min, and normal refractory periods with atrial extrastimulus techniques (His Purkinje system refractory periods less than 370 msec). The patient died from a cerebral embolus incurred during diagnostic left heart catheterization 2 days after electrophysiological studies. Postmortem examination revealed calcific aortic stenosis with calcific impingement upon the pars membranacea resulting in compression of the distal His bundle and marked disruption of the proximal portions of both bundle branches. This report documents a major limitation of electrophysiological studies, this limitation being that these studies may be totally normal on one occasion in a patient with pathologically significant chronic conduction disease, which may become clinically manifest on another occasion. (27 references.)