Treatment/management:
Treatment of acquired third-degree AV block is a class 1 indication for
pacer insertion. However, congenital third-degree AV blocks are usually
asymptomatic as AV nodes will take over the function of the sinus node
with normal heart rate adjustment with activities. Initially, he was
very symptomatic and therefore, pacer insertion would have been
appropriate. However, he refused pacer insertion initially due to his
excellent functional capacity. Electrophysiological testing of his
conduction system could have been helpful in order to get more
information about the location of the AV block and any potential
conduction response to pacing. However, the patient also refused any
further electrophysiological testing and finally underwent permanent
dual chamber pacer insertion 3 months later due to persist third degree
AV-block and severe bradycardia with limited functional capacity.