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PubMed2001

Prospective evaluation of a simplified approach for common atrial flutter radio frequency ablation with only two catheters.

UNLABELLED: Intra-atrial conduction block within the inferior vena cava-tricuspid annulus isthmus (IVCT) has been shown to predict successful common atrial flutter ablation. However, its demonstration requires the use of several electrode catheters and mapping of the line of block. The aim of this study was prospectively to test the feasibility of a simplified ablation procedure using only two catheters. METHODS: Radio frequency (RF) ablation of common atrial flutter was performed in 30 patients with the sole use of a catheter for atrial pacing and a RF catheter. RF ablation lesions were created in the IVCT. Surface ECG criteria were used to monitor the conduction within the IVCT. The end point during low lateral atrial pacing was an increment in the interval between the pacing artefact and the peak of the R wave in surface lead II >50 ms and clockwise rotation of the P wave axis beyond -30 degrees and inferiorly. Then, the line of lesions was mapped during atrial pacing with the RF catheter. Additional RF lesions were applied if mapping disclosed a zone of residual conduction. Otherwise the procedure was stopped if mapping showed parallel double potentials all along the line. Finally, the block was reassessed with a 'Halo' catheter. RESULTS: Surface ECG criteria were met in 26 patients. Mapping the line of lesions showed a complete corridor of parallel double potentials in these 26 cases and in 3 of the 4 patients in whom ECG criteria were not met. Conduction evaluated with the Halo catheter showed bi-directional complete block in these 29 patients. After a follow-up of 16 +/- 4 months there was no recurrence of atrial flutter. CONCLUSION: Surface ECG criteria combined with mapping of the line of block demonstrate evidence of bi-directional IVCT block. This simplified RF ablation of common atrial flutter is feasible with a low recurrence rate.

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PubMed1998

Role of autonomic tone in facilitating spontaneous onset of typical atrial flutter.

OBJECTIVES: This study sought to study the change in autonomic tone that precedes the initiation of paroxysmal atrial flutter. BACKGROUND: An abrupt change in the autonomic tone of the heart is an important initiating factor in the pathogenesis of ventricular tachyarrhythmias and paroxysmal atrial fibrillation. Whether the autonomic tone has a role in the initiation of paroxysmal atrial flutter has not been reported. METHODS: Holter electrocardiographic recording was used to investigate the changes in heart rate variability before the onset of paroxysmal atrial flutter. RESULTS: A total of 12 patients with paroxysmal atrial flutter were analyzed. An increase in the normalized value of the low frequency (LF) component and the LF/high frequency (HF) ratio and a decrease in the normalized value of the HF component began at 6 min before the onset of episodes of paroxysmal atrial flutter, which indicated that sympathovagal balance had shifted to more sympathetic predominance. CONCLUSIONS: An increase in sympathetic modulation or vagal withdrawal, or both, may facilitate the initiation of atrial flutter.

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PubMed1997

Risk of thromboembolism in chronic atrial flutter.

Anticoagulant therapy is not conventionally used in the treatment of patients with atrial flutter. This recommendation has been based on sparse clinical experience, and recent preliminary reports suggest a significant risk of thromboembolism for these patients. A retrospective study was undertaken to assess the frequency of thromboembolic events as well as potential risk factors for these events in a cohort of patients with atrial flutter referred for radiofrequency ablation treatment. Eighty-six consecutive patients with a primary diagnosis of atrial flutter were evaluated. A history of embolic events was noted in 12 of 86 patients (14%) with atrial flutter, with an annual risk of approximately 3%. There were no differences in the prevalence of coronary artery disease, cardiomyopathy, valvular disease, or atrial fibrillation between the 2 groups of patients having an embolic event and those of patients without embolic events. Left ventricular function and left atrial size were also similar between the 2 groups. The only significant risk factor was hypertension (p < 0.05). However, in a regression model with other clinical variables (i.e., age, gender, left atrial size, presence or absence of any cardiac disease, length of time in flutter, left ventricular function, type of flutter, flutter cycle length, type of secondary arrhythmias) no significant predictors were found. Patients with transient ischemic attacks or pulmonary emboli were then excluded from the analysis in order to compare the thromboembolic risk in the present study to that reported in major atrial fibrillation trials. The overall risk becomes 7% (6 of 86), which over a mean follow-up period of 4.5 years yields an annual risk of approximately 1.6%. Although this risk is only 1/3 of that for patients with atrial fibrillation, this risk is higher than previously recognized for patients with chronic atrial flutter. Anticoagulant therapy should be seriously considered for these patients.

Adult↗
PubMed2000

Cardioversion of persistent atrial flutter in non-anticoagulated patients at low risk for thromboembolism.

BACKGROUND: The true risk of thromboembolic events after cardioversion of atrial flutter was not addressed carefully. Nevertheless, thromboembolic events were thought to be rare and less likely to occur after cardioversion of atrial fibrillation. The aim of this study was to prospectively evaluate if the interruption of persistent typical atrial flutter could be safely performed without anticoagulation in a group of patients at low risk for thromboembolic events. METHODS: We studied 64 subjects selected among 138 consecutive patients with persistent typical atrial flutter (minimal duration 72 hours) in whom a transesophageal atrial pacing was performed in our electrophysiology laboratory from October 1994 to May 1999. Exclusion criteria included: anticoagulation therapy during the previous 4 weeks; previous history of atrial fibrillation; recent (< 1 month) myocardial infarction; history of thromboembolic events; left ventricular ejection fraction < 40%; presence of moderate or severe mitral regurgitation or stenosis; induction of sustained (> 6 hours) atrial fibrillation during transesophageal atrial pacing. Patients in whom atrial flutter persisted in spite of transesophageal atrial pacing underwent external direct current cardioversion or right atrial overdrive pacing within 24 hours. Thromboembolic events were checked for 4 weeks after the restoration of sinus rhythm. RESULTS: Sinus rhythm was restored in 54 patients by transesophageal atrial pacing, in 8 patients by electrical cardioversion, and in 2 by right atrial pacing. The mean duration of atrial flutter was 18 +/- 19 days, the mean left atrial size 41.3 +/- 6.2 mm, and the mean left ventricular ejection fraction 54.8 +/- 7.3%. During the study period no episodes of thromboembolism were recorded. CONCLUSIONS: Cardioversion of persistent typical atrial flutter in non-anticoagulated patients at low risk for thromboembolic events appears safe.

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PubMed1996

Anatomically based ablation of atrial flutter in an acute canine model of the modified Fontan operation.

BACKGROUND: Lateral tunnel total cavopulmonary connection, also called the modified Fontan operation, uses a baffle through the right atrium. We established, in an acute canine model, that atrial flutter after total cavopulmonary connection revolves around a line of conduction block imposed by the free wall lateral tunnel suture line. We hypothesized that a line of conduction block between the free wall total cavopulmonary connection suture line and the tricuspid anulus would interrupt atrial flutter in this model. OBJECTIVE: Our objective was to determine whether a cryolesion placed between the free wall total cavopulmonary connection suture line and the tricuspid anulus would terminate atrial flutter in an acute canine model. METHODS: Seven adult dogs underwent median sternotomy and institution of cardiopulmonary bypass. A suture line was placed through a right atriotomy to simulate total cavopulmonary connection lateral tunnel construction. Form-fitting 253-point biatrial endocardial mapping electrodes were placed via bilateral ventriculotomies. Atrial flutter was induced by atrial burst pacing. A cryothermal lesion was then placed between the free wall total cavopulmonary connection suture line and the tricuspid anulus in the low lateral right atrium (i.e., CRYO 1 procedure), and reinduction of atrial flutter was attempted. If atrial flutter was reinduced, the cryolesion was modified superiorly to include the caudal portion of the atriotomy (i.e., CRYO 2 procedure). Activation sequence maps were generated for sinus rhythms before and after the cryolesions were placed and for induced arrhythmias. RESULTS: In all seven cases, atrial flutter was inducible after suture line placement, before placement of a cryolesion. The reentrant circuit incorporated both caval orifices in five of seven cases and was successfully ablated by the CRYO 1 approach in each case. Atrial flutter was not inducible after placement of the CRYO 2 lesion in the remaining two cases, in which breakthrough of the wave front occurred across the lateral tunnel suture line in the intercaval region. Activation sequence maps of sinus rhythm after placement of the cryolesions demonstrated a conduction block at the site of the lesion. CONCLUSIONS: A linear cryothermal lesion placed between the free wall aspect of the total cavopulmonary connection suture line and the tricuspid anulus created a line of conduction block that successfully ablates atrial flutter in the canine model.

Acute Disease↗
PubMed2003

Atrial flutter after coronary artery bypass grafting: proposed mechanism as illuminated by independent predictors.

OBJECTIVE: The aim of this study was to evaluate the cause and treatment of atrial flutter after coronary artery bypass grafting (CABG). METHODS: Between July 1999 and July 2000, 96 CABGs were performed at the Cardiovascular Center of Aichi Prefectural Owari Hospital. We compared two groups of patients: those with atrial flutter after CABG (group A) and those without atrial flutter (group B). RESULTS: We treated the atrial flutter group with medication, electrical defibrillation, and overdrive pacing. Six of these cases later required radiofrequency catheter ablation (RFCA). These were all with common-type atrial flutter, treated by RFCA for the posterior isthmus, without difficulty. The frequency of direct cannulation to the coronary sinus for retrograde cardioplegia was significantly higher in group A. CONCLUSIONS: Incidence of atrial flutter after CABG was influenced by surgical damage arising from direct cannulation to the coronary sinus for retrograde cardioplegia. Preoperative viability of the myocardium (in addition to good myocardial protection during surgery) also seems to be associated with an increased likelihood of postoperative atrial flutter.

Aged↗
PubMed1994

Circus movement atrial flutter in the canine sterile pericarditis model. Relation of characteristics of the surface electrocardiogram and conduction properties of the reentrant pathway.

OBJECTIVES: This study was designed to elucidate the basis for the electrocardiographic (ECG) appearance of atrial flutter in the canine sterile pericarditis model. BACKGROUND: During atrial flutter, the surface ECG may show typical F waves or isolated P waves of any polarity. METHODS: Electrocardiographic leads II, III and aVF and epicardial atrial activation maps constructed from 127 simultaneously recorded bipolar electrograms were compared in 20 dogs with sterile pericarditis and inducible atrial flutter. RESULTS: In 10 dogs with F wave atrial flutter, single loop reentry occurred around combined functional/anatomic obstacles that included one or both caval veins and a vertically oriented arc of functional conduction block. In 10 dogs with P wave atrial flutter, a merely functional (n = 4) or combined (n = 6) obstacle involving any atrial vessel and more vertically (n = 5) or more horizontally (n = 5) oriented arcs of block was present. The isoelectric interval between P waves corresponded to the conduction time within the slow zone of the reentrant circuit (96 +/- 27 vs. 100 +/- 24 ms, mean +/- SD). Slow conduction accounted for 65 +/- 8% of the cycle length in P wave atrial flutter, but for only 29 +/- 7% in F wave atrial flutter (p < 0.05). Slow conduction was usually associated with activation of fewer than five epicardial electrodes per 10-ms isochronal interval, reflecting only a small amount of atrial tissue. The polarity of P or F waves was determined by the direction of the major wave front activating the most electrodes per 10-ms isochronal interval, irrespective of whether the right or the left atrium was activated. CONCLUSIONS: The F waves result from reentrant activation at a relatively constant speed around a vertically oriented functional/anatomic obstacle involving one or both caval veins. The P waves occur when the circuit contains a marked area of slow conduction.

Animals↗
PubMed1999

Electrophysiologic study and radiofrequency catheter ablation of isthmus-independent atrial flutter.

INTRODUCTION: We report the electrophysiologic study and radiofrequency catheter ablation of isthmus-independent atrial flutter in 2 patients. The isthmus-independent atrial flutter in these 2 patients had similar ECG and electrophysiologic findings. Both were reproducibly induced by rapid atrial pacing. The atrial activation sequence and entrainment study proved that these atrial flutters were not isthmus-dependent. A high-right atrial site was identified as the critical site of the slow conduction zone of the tachycardia in both. This site showed double potentials and mid-diastolic potentials. Radiofrequency catheter ablation at this site successfully eliminated the isthmus-independent atrial flutter in both patients.

Atrial Flutter↗
PubMed1996

[Specific percutaneous radiofrequency ablation of atrial flutter].

Radiofrequency catheter ablation has recently been successfully applied to patients suffering from atrial flutter. We report our experience in the ablation of typical atrial flutter in 17 consecutive patients refractory to drug treatment. The procedure was initially successful restoring sinus rhythm in 16 patients (94%). During a mean follow-up of 9 months atrial flutter recurred in 4 patients (23%). A second procedure was successfully performed in 2 patients; the other two patients are presently in sinus rhythm under amiodarone which was formerly ineffective. Finally, 59% of the patients were able to discontinue antiarrhythmic medication. In 4 out of 7 patients with dilated cardiomyopathy, the left ventricular ejection fraction normalized a few weeks after ablation. This successful technique should be considered early in the therapeutic approach to patients suffering from typical atrial flutter, to avoid numerous drug treatments, multiple hospitalizations and possible evolution toward non reversible dilated cardiomyopathy.

Adult↗
PubMed1978

Electrophysiological studies in four patients with atrial flutter with 1:1 atrioventricular conduction.

Electrophysiological studies of atrioventricular conduction during rapid atrial overdrive pacing and during programmed premature atrial stimulation are reported in four patients with an unusually rapid 1:1 ventricular response to atrial flutter (ventricular rates 240 to 310 per minute). Second-degree AV block development during atrial overdrive pacing at rates well below those during spontaneous atrial flutter. Although none of the four patients showed evidence of pre-excitation on the standard 12-lead electrocardiogram, evidence suggesting a partial AV nodal bypass was demonstrated at electrophysiological study in one case. It is postulated that the profile of the atrial wavefront presented to the normal AV node by atrial flutter differs from that during high right atrial pacing and may account for the lower ventricular rates achieved during high right atrial overdrive pacing than during spontaneous atrial flutter in the remaining three cases.

Adult↗
PubMed1998

Electrophysiologic characteristics of a dilated atrium in patients with paroxysmal atrial fibrillation and atrial flutter.

This study investigated the difference of atrial electrophysiologic characteristics between a normal and dilated atrium and compared them among patients with paroxysmal atrial fibrillation and flutter. Twenty-seven patients with paroxysmal atrial fibrillation and 28 patients with paroxysmal atrial flutter were divided into four subgroups, according to the presence of a normal atrium or bilateral atrial enlargement. Thirty patients without atrial arrhythmia (20 patients with normal atrium and 10 patients with bilateral atrial enlargement) were included in control group. The atrial refractoriness in patients with a dilated atrium was longer than those with normal atrial size. In patients with paroxysmal atrial fibrillation and patients of control group, the P-wave duration and interatrial conduction velocity with or without atrial enlargement were similar. However, in patients with paroxysmal atrial flutter, P-APCS (86 +/- 10 ms vs. 73 +/- 9 ms, p < 0.05) and P-ADCS (109 +/- 9 ms vs. 95 +/- 9 ms, p < 0.05) in patients with a dilated atrium were longer than in patients with a normal atrium. The patients with paroxysmal atrial fibrillation or atrial flutter all demonstrated longer P-wave duration and interatrial conduction time than control group. Among the groups with a normal atrium or a dilated atrium, atrial refractoriness in patients with paroxysmal atrial flutter was shorter than that in control group. Moreover, in the patients with a normal atrium, the potential minimal wavelength in control group (6.6 +/- 1.7) was longer than that of paroxysmal atrial fibrillation (5.3 +/- 1.1), or atrial flutter (5.0 +/- 1.2). These findings suggest that atrial electrophysiologic characteristics of a dilated atrium were different from those of normal atrium, and these changes were different between paroxysmal atrial fibrillation and flutter. Multiple factors are considered to be related to the genesis of atrial tachyarrhythmias.

Aged↗
PubMed1999

Effects of radiofrequency catheter ablation on quality of life in patients with atrial flutter.

The long-term effects of radiofrequency catheter ablation on quality of life in patients with typical atrial flutter are still unknown. This study included 100 consecutive patients with clinically documented typical atrial flutter. Subjective perception of quality of life was assessed by a semiquantitative questionnaire before, and 1 and 6 months after ablation. Ablation of typical atrial flutter was associated with a significant improvement in the general quality of life, frequency of significant symptoms, and symptoms during attacks. The frequency of hospital admission and emergency room visits, and number of antiarrhythmic drugs significantly decreased after ablation. Activity capacity significantly improved after ablation in patients with depressed left ventricular function. All improvements after ablation were maintained over 6-month follow-up. However, patients with atrial fibrillation compared with those without atrial fibrillation before ablation had less improvement in the general quality of life, frequency of significant symptoms, and symptoms during attacks (including palpitation, asthenia, effort, dyspnea, rest dyspnea, and dizziness). Furthermore, patients with atrial fibrillation before ablation needed more antiarrhythmic drugs, and had a higher frequency of hospital admission and emergent room visits at 6-month follow-up (all variables p <0.01). Multivariate analysis demonstrated that only the presence of atrial fibrillation before ablation could independently predict improvement in general quality of life (p = 0.03), frequency of significant symptoms (p = 0.03), symptoms during attacks (p = 0.04), and decrease in the consumption of health care resources including antiarrhythmic drugs (p = 0.01), hospital admission (p = 0.02), and emergency room visits (p = 0.02). Ablation of typical atrial flutter could significantly improve quality of life, but patients who had atrial flutter associated with atrial fibrillation before ablation had less improvement than those without atrial fibrillation.

Activities of Daily Living↗
PubMed1983

High resolution recordings of atrial flutter.

We present high resolution tracings of atrial flutter which, to our knowledge, have not been previously described. Two patients have been studied; in both cases atrial activity was made by waves similar to each other, differing only in voltage. We discuss the nature of these waves, which are probably related to continuous atrial activity, with a segregation into small and large waveform activity. It is concluded that high resolution recordings may be valid support for the interpretation of atrial flutter activity.

Atrial Flutter↗
PubMed1994

[Atrial fibrillation and atrial flutter: pathophysiology and pathogenesis].

Chronic atrial fibrillation is a very common arrhythmia affecting 2 to 4% of the population older than 60 years of age. Atrial fibrillation may cause disabling symptoms and serious adverse effects, such as impairment of cardiac function or thromboembolic events. It is also associated with an increased risk of death. In the past, the most common underlying heart disease related to chronic atrial fibrillation was rheumatic heart disease. Today, this disease occurs relatively rarely. Nevertheless, the incidence of atrial fibrillation is likely to increase in the future due to the aging of the population, since its prevalence increases with age. In most patients with chronic atrial fibrillation, the arrhythmia can be attributed to organic heart disease or metabolic disorders. In western countries ischemic and hypertensive heart disease (including sick sinus syndrome) and alcohol (holiday heart syndrome) are numerically more important than the classical causes of atrial fibrillation--rheumatic heart disease and thyrotoxicosis--which are declining in incidence. Overall, atrial fibrillation is associated with an increased mortality. In about 15% of patients with chronic atrial fibrillation, no underlying cardiac or metabolic abnormality can be found, also the arrhythmia can itself give right to atrial dilatation. Atrial fibrillation consists most probably of several coexisting reentrant wave fronts of activation within the atria. Atrial activation and atrial fibrillation is as follows: multiple wavelets sweep round the atria in irregular, shifting patterns; completed reentrant circuits are the exception. Atrial flutter in its common form is characterized by evidence of atrial activity at a rate of 250-350 bpm, and usually almost exactly 300 bpm.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1986

Demonstration of macroreentry and feasibility of operative therapy in the common type of atrial flutter.

Two patients are described who had recurrent and long-standing atrial flutter of the common type and were referred for electrophysiologic testing and surgical management. In both patients, atrial flutter could be initiated and terminated by programmed stimulation. Atrial endocardial mapping showed earliest activation during flutter at the orifice of the coronary sinus, with activity proceeding to the low atrial septum, high lateral right atrium and low right atrium, respectively. Programmed atrial extrasystoles from the high right atrium at a time when the atrial septal region was refractory advanced atrial flutter in proportion to prematurity of the extrastimulus, while maintaining the low to high activation sequence. Intraoperatively, epicardial atrial mapping revealed a large right atrial reentrant circuit beginning in the posteroseptal region and proceeding superiorly and laterally through the right atrial free wall before returning to its starting point. The narrowest part of the circuit and that showing relatively slow conduction during atrial flutter was observed in the low right atrial tissue between the tricuspid valve ring and the orifices of the inferior vena cava and proximal coronary sinus, respectively. Cryosurgical ablation around the orifice of the coronary sinus and surrounding atrial wall has prevented recurrent atrial flutter over short term follow-up in both patients, although 1 of the patients has required antiarrhythmic therapy for postoperative atrial fibrillation.

Atrial Fibrillation↗
PubMed2004

[Successful control of rapid heart rate with atrial flutter by intravenous administration of esmolol in a patient after total correction of the tetralogy of Fallot].

A 30-year-old woman with atrial flutter after surgical correction of tetralogy of Fallot, underwent gynecological procedure under general anesthesia. Because she had been noted to have atrial flutter and heart failure at 8 weeks' gestation, she was scheduled for dilatation and curettage. Chest X-ray film showed cardiomegaly and pulmonary congestive changes. ECG showed atrial flutter with 3:2 atrio-ventricular conduction rate and complete right branch block. She was anesthetized with propofol infused with target-controlled infusion system, fentanyl and 66% of nitrous oxide under close monitoring and appropriate respiratory management. The quantity of hemorrhage was about 850 ml, and hypovolemia was treated with volume infusion and the use of vasoactive drugs. Soon after emergence from anesthesia, atrial flutter with 1:1 A-V conduction (> 230 bpm) occurred suddenly. Esmolol hydrochloride, 30 mg, was administered. Despite the relatively low doses, rapid control of heart rate was possible in a few minutes and the atrial flutter returned to 2:1 conduction. Although atrial flutter had continued until the discharge, tachyarrhythmia was no longer observed and the heart resumed sinus rhythm 3 month after the operation. The present case suggests that esmolol can be used effectively and safely for controling atrial flutter with rapid ventricular response in a patient after surgical correction of tetralogy of Fallot.

Adrenergic beta-Antagonists↗
PubMed1997

Late recurrence of atrial flutter following radiofrequency catheter ablation.

The success rate for catheter ablation of atrial flutter has been reported to be approximately 90%, but recurrences are common and can be seen in up to 20% of cases. Most of these recurrences are seen within a few weeks following ablation. We report on a patient who developed a recurrence of type I atrial flutter 2 years after an initially successful radiofrequency catheter ablation procedure. Whether the recurrent atrial flutter is due to a new reentrant circuit resulting from slow progression of atrial disease or due to the changes produced by radiofrequency energy in the nearby myocardium is not clear. Further work to define the electrophysiological changes in the atrial myocardium produced by radiofrequency energy, as well as long-term follow-up of patients undergoing radiofrequency catheter ablation for atrial flutter may help in answering these questions.

Atrial Flutter↗
PubMed1996

Thromboembolism following cardioversion of "common" atrial flutter. Risk factors and limitations of transesophageal echocardiography.

Based on multiple recent studies, anticoagulant therapy is recommended prior to elective cardioversion for patients with atrial fibrillation of more than 24 h duration. The value of anticoagulation in patients with atrial flutter, however, is less well established. Published recommendations for pericardioversion anticoagulation of atrial fibrillation often do not extend to patients with atrial flutter. We evaluated the risk of thromboembolism in our patient population undergoing cardioversion for atrial flutter. Over a period of 30 months, clinically indicated electrical cardioversions were performed in 41 patients with "common" atrial flutter. Sixteen of these patients underwent transesophageal echocardiograms immediately prior to cardioversion to exclude a left atrial thrombus. Three of the 41 patients with atrial flutter developed neurologic ischemic syndromes within 48 h of elective cardioversion. All three patients who developed ischemic neurologic complications had undergone transesophageal echocardiography immediately prior to cardioversion and did not have any evidence of left atrial clot. One patient had cardiomyopathy and the other two had left ventricular hypertrophy. Thus, electrical cardioversion without anticoagulation in patients with atrial flutter and associated heart disease is associated with a risk of thromboembolic events. A normal transesophageal echocardiogram is of doubtful value in prevention of thromboembolic complications.

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