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.