Lev’s Disease Presenting with Complete Atrioventricular Block in a Patient with Severe Aortic Stenosis: A Case Report

Abstract

Lev’s disease is an age-related degenerative conduction disorder characterized by progressive fibrosis and calcification of the His-Purkinje system and adjacent structures. It typically manifests in elderly patients as advanced atrioventricular (AV) block and is often associated with calcific valvular disease. This case report describes a 74-year-old man with a history of stable, non-obstructive coronary atherosclerosis who presented with dizziness and was found to have complete AV block with a ventricular escape rhythm of 36 beats per minute. Transthoracic echocardiography demonstrated severe aortic stenosis with an aortic valve area of 0.96 cm2. Contrast-enhanced computed tomography revealed extensive aortic valve calcification extending into the interventricular septum, raising strong clinical-radiological suspicion of Lev’s disease due to the anatomical proximity of the His bundle. Surgical risk stratification using Society of Thoracic Surgeons and European System for cardiac operative risk evaluation II indicated an elevated operative risk. Given the patient’s advanced age, severe symptomatic aortic stenosis, and persistent conduction abnormality, the multidisciplinary Heart Team recommended transcatheter aortic valve implantation (TAVI) rather than surgical replacement. The patient underwent successful TAVI followed by dual-chamber pacemaker implantation for persistent AV block and remained pacemaker-dependent with a stable rhythm and resolution of symptoms during follow-up. This case underscores that degenerative conduction disease may remain clinically silent until irreversible AV block occurs. Unlike most reports describing new-onset conduction disturbances after TAVI, our patient already presented with complete AV block and imaging demonstrated extension of septal calcification involving the conduction system. Although histopathological confirmation and prior serial electrocardiogram were unavailable, this case highlights the potential role of advanced imaging in identifying patients at increased risk for permanent pacemaker dependence, thereby enabling more accurate risk stratification and guiding closer follow-up. ©Copyright 2025 by the Cardiovascular Academy Society.