A 38-year-old man presented with exertional dyspnea and dizziness. Six months earlier, he had attended the Emergency Department following a brief syncopal episode while exercising. There were no constitutional symptoms, and no family history of inherited cardiac disease or sudden cardiac death. Past medical history was significant for Granulomatosis with Polyangiitis (GPA), with previous pulmonary hemorrhage and recurrent sinusitis requiring surgical intervention. He had been treated for a vasculitis flare in the past year. Clinical examination revealed an early diastolic murmur. An electrocardiogram showed first degree heart block with a PR interval of 400 ms and right bundle branch block, and Mobitz type II second degree atrio-ventricular (AV) block during exercise. Inflammatory markers were elevated with C-reactive protein 45 (NR <4 mg/L) and erythrocyte sedimentation rate 44 (NR <22 mm/hr). cANCA was weakly positive with anti-proteinase-3 titer 11 units (717 units when GPA first diagnosed and 53 units at prior relapse). An infection screen and troponin I were negative. Renal function was normal. A chest radiograph showed no pulmonary infiltrates. At night, he developed complete heart block (CHB) with a rate of 30 bpm (Figure 1A), but remained asymptomatic without hemodynamic disturbance.