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PubMed2002

Usefulness of phased-array intracardiac echocardiography for the assessment of left atrial mechanical "stunning" in atrial flutter and comparison with multiplane transesophageal echocardiography(*).

We compared transesophageal and phased-array intracardiac echocardiography (TEE/ICE) for the 2-dimensional and spectral Doppler assessment of left atrial (LA) mechanical function. TEE is commonly used to assess LA body and LA appendage mechanical function in patients who are undergoing radiofrequency ablation of typical atrial flutter. Fifteen patients underwent TEE and ICE imaging before and after ablation of typical atrial flutter. The following parameters were measured: (1) LA appendage emptying velocity and fractional area change, (2) severity of LA spontaneous echo contrast (graded 0 to 4), (3) maximal inflow velocity of the left and right upper pulmonary veins, and (5) maximal mitral valve E- and A-wave inflow velocities in sinus rhythm. Diagnostic quality imaging was achieved in all patients with TEE and ICE. Comparing TEE and ICE, the following absolute values and linear correlation coefficient (R) were obtained: preablation LA appendage emptying velocity: 0.45 +/- 0.21 versus 0.44 +/- 0.21 m/s (r = 0.95, p = <0.001); postablation LA appendage velocity: 0.33 +/- 0.24 versus 0.34 +/- 0.24 m/s (r = 0.97, p <0.001); LA appendage fractional area change: 35.3 +/- 13.7 versus 35.9 +/- 17.1% (r = 0.81, p <0.001); left upper/right upper pulmonary vein inflow velocity: 0.50 +/- 0.17/0.49 +/- 0.18 versus 0.51 +/- 0.17/0.47 +/- 0.20 m/s (r = 0.93/0.90, p <0.001); mitral valve E/A wave: 0.66 +/- 0.14/0.31 +/- 0.14 versus 0.69 +/- 0.17/0.35 +/- 0.23 (r = 0.84/0.97, p <0.002); LA spontaneous echo contrast (pre- and postablation): 1.1 +/- 1.2/1.3 +/- 1.2 versus 1.2 +/- 1.3/1.4 +/- 1.3 (r = 0.92/0.90, p <0.001). No patients were identified with LA appendage thrombus. Thus, TEE and phased-array ICE provided equivalent imaging data with high statistical correlation. ICE may be an imaging alternative to TEE in the evaluation of a "stunned" left atrium.

Adult↗
PubMed2003

An atypical atrial flutter of focal origin: a study using a noncontact mapping system.

We report a case of focal atrial tachycardia with appearance suggestive of atypical atrial flutter in a 57-year-old man. Based on ECG criteria, tachycardia was misclassified as atypical atrial flutter. The electrophysiological study using a noncontact mapping system revealed a focal activity within the left upper pulmonary vein ostium. This case highlights the limitations of standard electrocardiographic and electrophysiological classifications of regular atrial tachycardia. This report also shows the relevance of new mapping techniques in the successful mapping and ablation of these arrhythmias, even those arising within the left atrium.

Atrial Flutter↗
PubMed1989

A clinical study of the application of endocardial fulguration in the treatment of recurrent atrial flutter.

Endocardial catheter fulguration has been recently proposed for treatment of arrhythmias originating within the right atrium. In this study the authors attempted to use this technique in eight patients with paroxysmal common atrial flutter. Numerous antiarrhythmic agents failed to prevent recurrences of the episodes, which occurred frequently over periods of at least 4 months. In every procedure, we used a 7F quadripolar catheter electrode introduced via the subclavian vein into the lower part of the right atrium. The two distal electrodes allowed the recording of bipolar double potentials where the critical slow pathway of the reentrant circuit was localized. A unipolar electrogram recording by the tip electrode gave us the location of the area to be ablated when this electrogram was in complete concordance with a small step in the descending part of the F waves in II, III and aVF. This step corresponded to the very depolarization of the reentry area. A DC shock of 100 to 120 J was delivered between the tip electrode and a paddle applied to the left chest wall. Sinus rhythm resumed instantaneously. No mechanical or electrical complications were noted. Three patients are free of relapses without antiarrhythmic drugs (follow-up: 14 to 17 months); three others are also free of relapses, but antiarrhythmic agents were required for treatment of other supraventricular dysrhythmias (follow-up: 3 to 17 months); atrial flutter recurred within several days and persisted in spite of two more procedures in two patients. We conclude that endocardial catheter fulguration of paroxysmal and recurrent atrial flutter seems to be effective therapy. Nevertheless, more experience is required in order to confirm these results.

Aged↗
PubMed1997

Action of adenine derivatives on experimental atrial flutter in the canine heart.

We have studied the effects of adenosine (Ado) and adenosine derivatives on an experimental atrial flutter (AFL) in the canine heart. Moreover, we have assessed these adenine derivatives on some electrophysiological parameters (the conduction time and functional refractory period) of the posterior internodal pathway (PIP) and of the ordinary atrial myocardium (OAM). The adenosine derivatives assessed were adenosine 5'-monophosphate (AMP), adenosine 3' 5'-monophosphate (cAMP) and adenosine 5'-triphosphate (ATP). Ado, AMP, and cAMP transformed the atrial flutter into a short episode of atrial fibrillation that terminated spontaneously to sinus rhythm. This effect was prevented by previous blockade of A1 purinergic receptors with aminophylline, but not by parasympathectomy (vagotomy and atropine). ATP also suppressed the AFL, but in this case, sinus rhythm was achieved without an intermediate episode of atrial fibrillation, and the effect of ATP was not prevented by A1 purinergic blockade. Ado, AMP and cAMP extended the functional refractory period measured in the PIP, but reduced this parameter in the OAM (p < 0.01). The different response of atrial tissues to the adenosine and its monophosphate derivatives was not elicited by ATP. This derivative caused a prolongation of FRP on both atrial tissues PIP and OAM (p < 0.05). The changes produced by Ado and its monophosphate derivatives on FRP was blocked by aminophylline. The effect of adenine derivatives on AFL may be explained by the dispersion of refractoriness created as a result of the heterogeneous response of atrial tissues to these agents. Our results support the hypothesis of an agonistic action of adenine derivatives on atrial purinergic receptors.

Adenine↗
PubMed2004

Improvement of atrial signal-averaged electrocardiographic abnormalities after radiofrequency catheter ablation in persistent atrial flutter.

It has been reported that abnormalities of atrial conduction are present in patients with atrial flutter (AFL). We analyzed the P wave signal-averaged ECG (PSE) in patients after cardioversion of chronic AFL by radiofrequency catheter ablation (RFCA) to determine whether abnormalities of atrial conduction exist in patients with AFL and whether they recover. We studied 11 patients undergoing ablation of persistent AFL (AFL group), 11 patients with paroxysmal AFL (PAFL group), and 14 patients without any evidence of arrhythmias (control group). The PSEs were recorded 1 day, 7 days, and 1 month after RFCA. The filtered P wave duration (FPD) was calculated from the PSE recording. The FPD correlated with interatrial conduction time (r = 0.644) and left atrial dimension (r = 0.675) in combined assessment of the AFL and PAFL groups. The FPD was longer in the AFL group 1 day (165 +/- 14 ms, P < 0.001) and 1 month (150 +/- 18 ms, P < 0.05) after RFCA than in the control group (134 +/- 10 ms). Our findings suggest that atrial conduction abnormalities detected by PSE are present in patients with persistent AFL and improve 1 month after cardioversion.

Adult↗
PubMed1998

Acceleration of typical atrial flutter due to double-wave reentry induced by programmed electrical stimulation.

BACKGROUND: Acceleration of reentrant tachycardia induced by programmed electrical stimulation is a well-documented phenomenon, but the mechanisms remain poorly understood. METHODS AND RESULTS: Twelve patients with typical atrial flutter were studied. Activation sequence of the underlying reentrant circuit was recorded by multiple multipolar electrodes placed in the right atrium. In five patients, 27 episodes of atrial flutter acceleration were induced by single extrastimuli delivered in the isthmus between the tricuspid annulus and eustachian ridge (TA-ER isthmus) and one by rapid overdrive atrial pacing. Analyses of the activation sequences, intracardiac electrograms, and 12-lead surface ECG P-wave morphology indicated that the acceleration was caused by two successive activation wave fronts circulating in the same direction along the same reentrant circuit (double-wave reentry, DWR). DWR was induced only within a narrow range of coupling interval, from 2 to 45 ms beyond the effective refractory period, and was associated with unidirectional antidromic block of the paced impulse. Patients with DWR had a shorter effective refractory period (138.8+/-13.4 versus 163.8+/-12.2 ms, P<.015) and larger excitable gap (124.0+/-22.6 versus 83.2+/-13.2 ms, P<.009) compared with patients without inducible DWR. All of the DWR episodes were transient. Most (78.6%) terminated after one of the double wave fronts was blocked in the TA-ER isthmus. CONCLUSIONS: DWR is one of the mechanisms responsible for programmed electrical stimulation-induced atrial flutter acceleration in human subjects. Its induction requires a sufficient excitable gap and antidromic unidirectional block of the paced impulse in the TA-ER isthmus. In addition, the TA-ER isthmus is the usual site of DWR termination.

Adult↗
PubMed1975

[High-frequency electric stimulation of the atrium in treatment of supraventricular tachycardias and atrial flutter].

The authors report the results of rapid atrial stimulation in the treatment of 12 cases of junctional tachycardia (J.T.), 20 cases of atrial tachycardia (A.T.) and 43 cases of atrial flutter (A.F.). Sinus rhythm was restored in 91.6%, 70% and 60.4% of the cases for J.T., A.T. and A.F. respectively, either when pacing was discontinued or following a period of atrial fibrillation (from a few minutes to several hours). Fifteen per cent of the cases of A.T. and 25.5% of the cases of A.F. turned into stable atrial fibrillation with reduction of ventricular rate. The authors believe that this technique is a valuable alternative to D.C. countershock when medical treatment has proved ineffective and when countershock may be hazardous.

Adult↗
PubMed2006

Mitral valve prolapse, atrial flutter, and syncope in a young female patient.

BACKGROUND: The syndrome of mitral valve prolapse (MVP) is the most common form of valvular heart disease. CASE REPORT: The case of a 16-year-old girl with mitral valve prolapse, atrial flutter and syncope is presented. The patient was admitted to the clinic complaining of atypical chest pain, palpitations, breathlessness at physical efforts, fatigue, and a feeling of fogginess. Electrocardiogram showed the presence of the common-type atrial flutter with 3:1 ventricular responses. Echocardiography showed mitral valve prolapse with mild mitral regurgitation. The patient reported to have had these symptoms for about nine months. She was not aware of heart disease before. CONCLUSIONS: A young female patient with combined mitral valve prolapse, atrial flutter, and syncope is presented.

Adolescent↗
PubMed2001

Different patterns of interatrial conduction in clockwise and counterclockwise atrial flutter.

BACKGROUND: The terms counterclockwise (CC) and clockwise (C) atrial flutter (Afl) are used to describe right atrial activation around the tricuspid valve in the left anterior oblique view. The manner in which the left atrium is activated, as reflected by coronary sinus (CS) recordings, has not been systematically evaluated. METHODS AND RESULTS: Nine patients with both CC and C Afl underwent electrophysiological study with CS recordings during both rhythms with the use of a decapolar catheter with the tip placed in the distal CS. Patterns of CS activation during each type of Afl as well as during during sinus rhythm were categorized into 1 of 3 patterns: sequential proximal-to-distal, sequential distal-to-proximal, and fused, indicating activation from different directions. In 7 of 9 patients, the pattern of CS activation in CC Afl and C Afl differed, with a proximal-to-distal pattern in CC Afl and a fused pattern in C Afl. In 2 patients, pacing the high right atrial septum near the presumed site of Bachmann's bundle in sinus rhythm showed a similar fused pattern of CS activation. CONCLUSIONS: These results demonstrate different patterns of CS activation in CC Afl and C Afl in the majority of patients and are consistent with a model in which the left atrium is activated predominantly over Bachmann's bundle during C Afl and over the CS os in CC Afl. These findings may have implications for maintenance of Afl, interpretation of flutter wave morphology on surface ECG, and left atrial mechanical function in Afl.

Aged↗
PubMed2001

Prolonged fractionation of paced right atrial electrograms in patients with atrial flutter and fibrillation.

OBJECTIVES: This study investigated the extent of fractionation of paced right atrial electrograms in patients with and without paroxysmal atrial flutter (AFL) or atrial fibrillation (AF). BACKGROUND: Slow conduction through nonuniform anisotropic atrial muscles, represented by fractionated electrograms, may favor the generation of atrial tachyarrhythmias. METHODS: This study included 10 control patients (Group 1), 8 patients with documented paroxysmal AFL (Group 2) and 10 patients with documented paroxysmal AF (Group 3). Five electrode catheters were placed in the different sites of the right atrium and one catheter was positioned at the coronary sinus ostium. Atrial pacing from one site was done by a constant drive train with an extrastimulus inserted every fourth beat while recording at the other five sites was performed. The delay of each fractionated potential in the high-pass filtered atrial electrogram in response to extrastimulation was determined and used to construct conduction curves of delay versus the S1S2 interval. RESULTS: The mean increase in electrogram duration between a coupling interval of 350 ms and 10 ms above atrial refractoriness was significantly greater in Groups 2 and 3 compared with that in Group 1 (8.5 +/- 2.5 vs. 11.0 +/- 2.7 vs. 5.9 +/- 2.3 ms, respectively, p < 0.001). The mean S1S2 interval at which delay increased suddenly was also longer in Groups 2 and 3 compared with Group 1 (326 +/- 9 vs. 343 +/- 12 vs. 307 +/- 17 ms, respectively, p < 0.001). CONCLUSIONS: Increased delays in the individual potential of the fractionated atrial electrograms may be related to the development of AFL and AF.

Action Potentials↗
PubMed1989

[Atrial flutter with 1:1 AV conduction during intravenous flecainide treatment].

Acute drug treatment of recent onset atrial flutter may reduce the ventricular rate by increasing block in the A-V node (digitalis/verapamil) or act by directly affecting the atria by reducing the atrial rate or converting flutter to sinus rhythm (1a and 1c antiarrthythmic drugs). Treatment that reduces the atrial rate may cause 1:1 A-V conduction. Quinidine and disopyramide are well known for increasing A-V conduction to 1:1 in some patients, because of their anticholinergic effect on the A-V node. Flecainide, a 1c antiarrhythmic drug, slows down atrial conduction, reducing flutter rate by 1/3. Clinical studies have shown flecainide to be effective in converting atrial fibrillation, atrial tachycardia, A-V reentry and A-V nodal reentry tachycardias to sinus rhythm. The effect on atrial flutter has been less impressive. Flecainide prolongs A-V conduction and increases Wenckebach cycle length. In spite of this, 1:1 A-V conduction may occur during treatment with intravenous flecainide for atrial flutter. We present a case where this is demonstrated and review the literature.

Aged↗
PubMed2001

Atypical right atrial flutter patterns.

BACKGROUND: The purpose of our study was to define the incidence and mechanisms of atypical right atrial flutter. METHODS AND RESULTS: A total of 28 (8%) of 372 consecutive patients with atrial flutter (AFL) had 36 episodes of sustained atypical right AFL. Among 24 (67%) of 36 episodes of lower loop reentry (LLR), 13 (54%) of 24 episodes had early breakthrough at the lower lateral tricuspid annulus, whereas 11 (46%) of 24 episodes had early breakthrough at the high lateral tricuspid annulus, and 9 (38%) of 24 episodes showed multiple annular breaks. Bidirectional isthmus block resulted in elimination of LLR. A pattern of posterior breakthrough from the eustachian ridge to the septum was observed in 4 (14%) of 28 patients. Upper loop reentry was observed in 8 (22%) of 36 episodes and was defined as showing a clockwise orientation with early annular break and wave-front collision over the isthmus. Two patients had atypical right AFL around low voltage areas ("scars") in the posterolateral right atrium. CONCLUSIONS: Atypical right AFL is most commonly associated with an isthmus-dependent mechanism (ie, LLR or subeustachian isthmus breaks). Non-isthmus-dependent circuits include upper loop reentry or scar-related circuits.

Aged↗
PubMed2004

Postcardiac injury syndrome following radiofrequeny ablation of atrial flutter.

We report the case of a 64-year-old woman who was admitted to our hospital for radiofrequency ablation of isthmus-dependent counterclockwise atrial flutter. Following an initially uncomplicated right atrial linear isthmus ablation that was associated with conversion of atrial flutter to sinus rhythm and evidence of complete isthmus block, the patient developed a small pericardial effusion, a marked and recurrent left-sided pleural effusion, and had significantly elevated inflammatory markers. After an extensive diagnostic work-up which excluded infectious, malignant and thromboembolic causes of the effusions, a diagnosis of postcardiac injury syndrome was made and the patient was treated with oral corticosteroids and nonsteroidal anti-inflammatory drugs. Over a treatment period of 2 months there was complete resolution of the pericardial and left-sided pleural effusions and normalization of inflammatory markers. Postcardiac injury syndrome is a rare complication of radiofrequency ablation that is characterized by signs of pericardial, pleural and pulmonary parenchymal inflammation.

Adrenal Cortex Hormones↗
PubMed1998

[Uncommon atrial flutter related to cicatrix from atriotomy surgery: radiofrequency catheter ablation].

A patient with a complex congenital abnormality required the implantation of an interatrial septum patch through a right lateral atriotomy. Nine years later he developed two different morphologies of an incessant uncommon atrial flutter refractory to antiarrhythmic drug treatment. The electrophysiological study localized a site on the right atrium lateral wall where local activation time was 75 ms earlier than the onset of the P wave, transient entrainment with concealed fusion was obtained, the first postpacing interval after transient entrainment was 5 ms longer than tachycardia cycle length and the stimulus to P wave interval was 50 ms. At this site, radiofrequency delivery terminated the atrial flutter in less than 1 second. No further induction or recurrences of any morphology of the atrial flutter were observed after a four month follow up. These findings suggest the existence of a narrow conduction isthmus amenable to interruption by focal delivery of radiofrequency. The isthmus was most probably located between the atriotomy and the crista terminalis, posterior to the former and anterior to the latter.

Adult↗
PubMed1999

Atrial flutter in the recipient atrium induced by premature beats arising from the donor atrium 10 years after orthotopic heart transplantation.

BACKGROUND: Several mechanisms for the genesis of supraventricular arrhythmias in patients after orthotopic heart transplantation have been reported. METHODS AND RESULTS: We describe a 58-year-old male patient in whom atrial flutter occurred 10 years after orthotopic heart transplantation. During an electrophysiological study, bidirectional conduction between the recipient and donor atria was found. Atrial flutter in the recipient atrium was induced by programmed stimulation of the donor atrium using a single extrastimulus. The clinical symptoms were caused by atrial flutter arising from the recipient atrium with 1:1 to 3:1 conduction to the donor atrium. Mapping the anastomosis between the two atria indicated fragmented potentials at a discrete site of conduction. Delivery of radiofrequency energy at this site terminated conduction in both directions. Subsequent atrial pacing of the donor and recipient atria, respectively, demonstrated bidirectional conduction block. CONCLUSION: Symptomatic arrhythmias in patients after heart transplantation can indirectly originate from the donor atrium via bidirectional recipient-donor atrial conduction. This type of arrhythmia can be successfully treated with radiofrequency ablation.

Atrial Flutter↗
PubMed1999

[Thromboembolism following cardioversion of atrial flutter].

The risk of thromboembolism following cardioversion of atrial flutter (AFL) is considered low and anticoagulant treatment (ACT) is not recommended. Nevertheless echocardiographic findings in patients with AFL and several case stories in literature suggest that the risk has been underestimated. Two cases of cerebral embolism are described after cardioversion of AFL in patients without concomitant ACT. Until further studies are available the authors recommend that patients with AFL scheduled for cardioversion receive ACT according to the recommendations for atrial fibrillation.

Aged↗
PubMed1993

[A method of intensive therapy for atrial flutter].

The authors propose a new stepwise method of intensive therapy of atrial flutter (AF) based on atrial transesophageal pacing (ATEP) the efficacy of which was raised by previous digitalization. Patients of group 1 (n = 25) were scheduled to have ATEP, in its inefficacy ATEP was to be followed by antiarrhythmic drugs and on-demand cardioversion. In patients of group 2 (n = 27) ATEP was preceded by digitalization. ATEP and antiarrhythmic chemotherapy resulted in restoration of the sinus rhythm in 48% of the cases, cardioversion was performed in 11 patients of group 1. In group 2 normal rhythm was reestablished in 88% of the patients, 2 patients experienced cardioversion. The proposed variant of treatment is advocated as an alternative to cardioversion.

Adult↗