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An electrophysiologic study was performed in a 95-year-old man with bifascicular block (right bundle branch block and left anterior hemiblock). During sinus rhythm (AA interval = 980 ms), every sinus beat was conducted to the ventricle. The AH interval was 130 ms and HV interval was 50 ms. A programmed premature atrial stimulation was performed after 8 paced beats at a slightly shorter cycle length than the sinus cycle length (900 ms). As the atrial coupling interval was shortened, the H1H2 interval also shortened. At an H1H2 interval of 680 ms the premature atrial beat was blocked distal to the recording site of the His potential. The block persisted up to an H1H2 interval of 560 ms. AV conduction resumed paradoxically when the H1H2 interval was further shortened to intervals lasting 540-490 ms. During this period the H2V2 interval was 50 ms. At still shorter H1H2 intervals, H2 was again blocked. The H2V2 intervals during this phase of improved conduction were unchanged compared with those of other conducted beats. Therefore normalization due to the gap phenomenon could be ruled out, and the improved conduction could be explained by a phenomenon of supernormal conduction in the posterior division of left bundle branch.

An Elderly Case of Supernormal Conduction in the Posterior Division of the Left Bundle Branch.