Abstract
Intra-hisian atrioventricular (AV) block is not a common phenomenon, but it is important for the development of advanced or complete AV block. We observed a 77-year-old female patient with the 2:1 AV block due to an intra-hisian block. In this case we tried to detect the block site, but an alternating pattern of the AH conduction was noted on the His-electrogram in the electrophysiological study (EPS). The cause of the confusing finding might have been the instability of the catheter to record a His potential. We could detect a splitting of the His-electrogram with an intra-hisian block after minimal manipulation of the catheter. The authors’ observations suggest that catheter stability is important for a precise recording in the EPS and radiofrequency catheter ablation procedure.
Keywords: Cardiac electrophysiologic techniques, Bundle of His, Atrioventricular block
Core tip: Intra-hisian atrioventricular (AV) block associated with 2:1 AV block is an uncommon phenomenon, but it is important for the development of complete AV block. We observed a 77-year-old female with 2:1 AV block due to an intra-hisian block. An alternating pattern of the AH conduction was noted on the His-electrogram. The cause of that confusing finding might have been the instability of the catheter for recording the His potential. We could detect a splitting of the His-electrogram with intra-hisian block after minimal manipulation of the catheter. The authors’ observations suggest that catheter stability is important for a precise recording.
INTRODUCTION
Catheter stability is very important for achieving a precise electrophysiological study (EPS); 2:1 atrioventricular (AV) block is usually a disease of various levels such as supra-, intra- and infra-hisian[1,2]. We report a case with some confusion caused by the instability of the catheter used for the His-electrogram recording during 2:1 AV block due to an intra-hisian block.
CASE REPORT
A 77-year-old female complained of dizziness. Her past history had hypertension, and had been taking dihydrophyridine calcium channel blockers for 10 years. The chest radiograph showed cardiomegaly. The echocardiography revealed a normal function and wall motion. A resting electrocardiogram (ECG) revealed 2:1 AV block and right bundle branch block. After an intravenous injection of atropine and an exercise treadmill test, the ECG exhibited persistent 2:1 AV block.
The patient underwent an EPS to determine the position of the conduction block. EPS catheters located in right ventricle, His bundle and right atrium. Firstly, we found an infra-hisian block with a normal A-H interval (70 ms) and long H-V interval (70 ms) on the intracardiac ECG (Figure 1A), and then a supra-hisian block with longer A-H interval (100 ms) and shorter H-V interval (40 ms) (Figure 1B). After a while, another intracardiac ECG revealed a splitting of the His potential (H-H’) in the A-V conduction and only the proximal activation of the His potential during A-V block, which meant an intra-His bundle block (Figure 1C).
Figure 1.
Surface electrocardiograms with intra-cardiac electrocardiograms in sweep speed of 100 mm/s. Surface ECG shows 2:1 atrioventricular block with a right bundle branch block. A: Intra-cardiac ECG was located the right ventricular apex (RVA), His bundle (HIS), and right ventricular apex (RVA). Surface ECG revealed 2:1 atrio-ventricular block. Intra-cardiac ECG revealed infra-hisian block and short A-H interval (70 ms); B: Intra-cardiac ECG revealed supra-hisian block and long A-H interval (100 ms); C: The intracardiac ECG shows the splitting of the His potential (H-H’) during AV conduction and only the proximal activation of His potential during the AV block, which means an intra-hisian block. A: Potential of right atrium; H: Potential of proximal His bundle; H’: Potential of distal His bundle; V: Potential of right ventricle; ECG: Electrocardiogram.
The patient was performed the implantation of permanent pacemaker as a result of the intra-His bundle block. The patient has no other symptoms until now.
DISCUSSION
In our case, we tried to detect the block site but an alternating pattern of the AH conduction was noted in the His-electrogram during the EPS. The cause of this confusing finding might have been due to the instability of the catheter to record a His potential. However, the His potential was distinct in the first recoding of the His bundle (Figure 1A). In addition, the His potential spontaneously moved and the AH interval prolonged during the AV conduction, which concluded that the catheter was not stable.
A consistent intracardiac electrogram reflects a stable catheter position. Among the several catheters used during the EPS, the catheter used for the His-electrogram recoding is the most unstable in a beating heart. Catheter stability is important for obtaining a precise recording during the EPS and radiofrequency catheter ablation procedure. Instability of catheters can contribute to a misdiagnosis and procedural complications especially with AV nodal reentrant tachycardia. Recently, a remote magnetic navigation system is able to provide better catheter stability during the radiofrequency catheter ablation procedure[3]. However, that system cannot be used during diagnostic procedures such as in our study because of the high cost. Fortunately, we could detect the splitting of the His-electrogram with an intra-hisian block after a minimal manipulation of the catheter.
Intra-hisian AV block during 2:1 AV block is not a common phenomenon, but it tends to develop into advanced or complete AV block[4]. We should try to obtain a precise His electrogram and find the exact block site when conducting an EPS for 2nd degree high grade AV block.
COMMENTS
Case characteristics
A 77-year-old female complained of dizziness.
Clinical diagnosis
Intra-hisian atrioventricular (AV) block detected a splitting of the His-electrogram after a correction of the catheter instability during the electrophysiological study (EPS).
Differential diagnosis
Second-degree Mobitz 1 block with 2:1 AV is easily misdiagnosed as general two to one conductive rate regardless of block site.
Laboratory diagnosis
The laboratory test results were unremarkable.
Imaging diagnosis
The intracardiac electrocardiogram revealed splitting of the His potential of the AV conduction during the EPS.
Treatment
A permanent pacemaker was implanted as a result of intra-hisian AV block.
Related reports
To best of our knowledge, intra-hisian AV block is an uncommon phenomenon.
Term explanation
Intra-hisian AV block in His-electrogram exhibited a splitting of the His potential during the AV conduction and only the proximal activation potential of the His bundle during the AV block, which meant an intra-His bundle block.
Experiences and lessons
The authors should try to achieve a precise recording of the His electrogram and find the exact block site when conducting an EPS for 2nd degree high grade AV block.
Peer-review
It is an interesting case report.
Footnotes
P- Reviewer: Falconi M, Ho KM, Lazzeri C S- Editor: Tian YL L- Editor: A E- Editor: Lu YJ
Institutional review board statement: This is a clinical case report. The patient related identification information has been avoided according to the policy of Daegu Catholic University Medical Center Institutional Review Board.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All authors have no conflict-of-interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Peer-review started: February 22, 2015
First decision: April 10, 2015
Article in press: July 17, 2015
References
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