Alsagaff, Mochamad Y. and Ghea, Cornelia and Susilo, Hendri and Medistya Putri, Elisabeth Sekaringtyas (2026) Alternating Bundle Branch Block Despite a Patent Stent in Late-Presenting Extensive Anterior STEMI. JACC: Case Reports, 31 (20).

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Abstract

Background: Alternating bundle branch block (ABBB) is a rare but high-risk marker of advanced infra-Hisian disease and impending high-grade atrioventricular (AV) block in anterior ST-segment elevation myocardial infarction (STEMI). Case Summary: A 39-year-old male smoker presented 19 hours after chest pain onset with extensive anterior STEMI and ABBB. Ostial left anterior descending artery occlusion was treated with overlapping drug-eluting stents, achieving TIMI flow grade III. Despite patent stents, he developed delayed complete AV block. Temporary transvenous pacing restored hemodynamic stability, and AV conduction recovered within 24 hours. Discussion: Septal injury, edema, microvascular obstruction, or reperfusion injury can destabilize His-Purkinje conduction despite the presence of open epicardial arteries. Take-Home Message: ABBB warrants continuous monitoring and pacing readiness, even when angiography appears reassuring. © 2026 The Authors

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