[Gap, phase III and IV block and supernormal conduction of the right bundle branch]

Abstract

A recent review of the literature corroborated that several factors explained why supraventricular impulses falling gradually earlier in the cycle could traverse the His-Purkinje system while other impulses occurring later could fail to do so. The present report deals with the coexistence (in the same patient) of three distinct mechanisms whereby progressively more premature impulses could be "unexpectedly" conducted. Phase III left bundle branch block coexisted with the following conduction disturbances in the right bundle branch; late "pseudosupernormal" conduction sandwiched in between periods of phase III and phase IV block; intermediate "pseudosupernormal" conduction resulting from the so-called type 2 gap, during which propagation occurred, but with H-V intervals longer than later in the cycle; early "true" supernormal conduction (related temporarily to the end of the T wave) exposed when a premature ventricular beat reached the affected zone in a concealed retrograde fashion. These findings show how, with block late in the cycle, conduction in earlier part of the cycle was not always due to "true" supernormal conduction.