Second degree AV block pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
Pathophysiology
Mobitz Type I
The classic site of block in Mobitz type I second degree block is the AV node (70%-75%). In the remaining 25%-30% of the cases the site is infra-nodal (His bundle, bundle branches or fascicles). Mobitz type I is again composed of two variations which show Wenckebach periodicity: classic and atypical.
Classic
Classic variety usually occurs within the AV node. It can be observed in antegrade AV conduction and also in retrograde VA conduction across the AV node. There is a gradually increasing PR interval and eventually a dropped beat. There is also usually a gradually decreasing R-R interval. The PR interval is usually shortest in the initial beat and gradually increases ending in a dropped beat and the cycle repeats. If the interval between the last conducted beat and the first beat of the next cycle is very long, the first beat may be a junctional escape rhythm rather than a conducted beat. This classic Wenckebach phenomenon occurs usually with ratios of 3:2, 4:3 or 5:4. This results in grouped beating.
Atypical
This variant of Wenckebach pattern is defined as long Wenckebach and is also called pseudo-Mobitz type II pattern as it simulates Mobitz type II block. In this pattern the conduction ratios usually exceed 6:5 or 7:6 and the last few beats of the cycle, before a dropped beat, show a relatively constant PR interval (maximum variation of 0.02 sec among them). The beats after the dropped beat again show gradually prolonging PR intervals.[1]
Mobitz Type II
Conduction delay in Mobitz type II second degree block is almost always infra-nodal (His bundle [20%], bundle branches or fascicles). Usually the morphology of the QRS complex is wide, except when the site of block is the His bundle. In this variant of second degree heart block the PR interval is constant with occasional dropped beats as compared to the gradually prolonging PR interval in Mobitz type I. Bifascicular or trifascicular disease is seen in two thirds of the patients with Mobitz type II.