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PubMed2000

[Thromboembolic risk factors in atrial flutter. Transesophageal echocardiographic study].

BACKGROUND: The thromboembolic risk of atrial flutter (AFL) is not well defined. On the other hand, in atrial fibrillation (AF), the echocardiographic demonstration of thrombus or spontaneous echo contrast in the left atria or its appendage, a lower flow velocity in the left atrial appendage, and its reduced mobility, are well known risk factors of thromboembolism. AIM: To study the incidence of these echocardiographic risk factors in patients with AFL. MATERIAL AND METHODS: We prospectively studied 50 consecutive patients with AFL comparing them with two groups of patients with a well known increased risk of thromboembolism: 54 patients with AF and 24 patients with sinus rhythm and severe mitral stenosis (RSEMS). The group of patients with AFL was also compared with a control group of 27 patients with sinus rhythm and no increased risk of thromboembolism. In each group, we studied the presence of thrombi and spontaneous echo contrast in the left atria and left atrial appendage, emptying velocity (Vel A), filling flow (Vel B) and motility of the left atrial appendage and left atrial dimensions. RESULTS: When compared with control patients, AFL subjects had a higher incidence of spontaneous echo contrast in the left atria and left atrial appendage (11 and 42% respectively, p < 0.05); slower flow velocity in the left atrial appendage (Vel A 69.25 +/- 25 and 41 +/- 19 cm/s respectively, Vel B 55 +/- 16 and 46 +/- 20 cm/s respectively, p < 0.05); lower atrial appendage wall motility (4 and 84% respectively, p < 0.001) and a larger left atrium (40 +/- 10 and 45 +/- 0.6 mm respectively, p < 0.05). Patients with AFL had a lower incidence of echocardiographic abnormalities than subjects with AF or RSEMS. Thrombi were found in 2 patients with AFL, 12 patients with AF, 4 patients with RSEMS and in no control patient. CONCLUSIONS: In AFL, there are echocardiographic markers of increased thromboembolic risk in comparison with a control group. Nevertheless, the incidence of these factors is lower than in patients with AF or with RSEMS.

Adolescent↗
PubMed2004

Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients.

OBJECTIVES: In patients with atrial flutter (AFL) and postoperative right atrial incisional scars, we sought to assess if the use of additional ablative lesions that targeted all potential re-entrant circuits, regardless of the presenting type of flutter, would prevent long-term recurrence. BACKGROUND: Patients with AFL and incisional scars have a complex atrial substrate that may promote multiple mechanisms of intra-atrial re-entry. METHODS: Twenty-nine patients with single right atrial incisional scars undergoing ablation for scar-dependent (n = 15) and cavotricuspid isthmus (CTI)-dependent (n = 14) flutter were studied. RESULTS: In the scar-dependent group, 9 of 15 (60%) patients had inducible or spontaneous CTI-dependent flutter immediately after ablation. In the group with CTI flutter, 7 of 14 (50%) patients had scar-related flutter immediately after ablation. If a second type of flutter was found during the initial ablation, a second ablation was performed either along the isthmus (scar-dependent group) or from the scar to another anatomic boundary (isthmus-dependent group). Patients were followed for 24 +/- 5 months and 18 +/- 6 months in the scar- and CTI-dependent groups, respectively. In the scar-dependent group, five of six (83%) who underwent only a single flutter line had recurrence at 3 +/- 1 months. In the isthmus-dependent group, three of seven (42%) patients who had only one flutter line performed had recurrence at 5 +/- 3 months. There was no flutter recurrence in patients who initially received two different flutter lines or in patients who subsequently underwent a second flutter line at follow-up. CONCLUSIONS: In patients with postoperative right atrial incisional scar and flutter, multiple ablation lines that target both scar-related and classic isthmuses appear necessary to prevent long-term recurrence.

Atrial Flutter↗
PubMed2001

Sinus node recovery after 25 years of atrial flutter.

This case report demonstrates that the sinus node can recover relatively quickly even after being suppressed by atrial flutter for 25 years, and that a permanent pacemaker may not always be necessary in all patients with sinus arrest after a successful atrial flutter ablation.

Aged↗
PubMed2004

Early recurrence of arrhythmia in patients taking amiodarone or class 1C agents for treatment of atrial fibrillation or atrial flutter.

Amiodarone use for the prevention of recurrent atrial fibrillation or atrial flutter requires drug loading over a period of several days to weeks, whereas class 1C agents do not. Three hundred thirty-nine patients were evaluated during drug loading with amiodarone or class 1C agents, and it was found that recurrent arrhythmia was common, usually not persistent, and frequently asymptomatic. Recurrent arrhythmia was not more common with amiodarone.

Age Factors↗
PubMed2003

Global right atrial mapping delineates double posterior lines of block in patients with typical atrial flutter: a study using a three dimensional noncontact mapping system.

UNLABELLED: Double Posterior Lines of Block in Typical Atrial Flutter. INTRODUCTION: The crista terminalis (CT) has been shown to be a barrier to transverse conduction during typical atrial flutter (AFL). However, some studies have demonstrated the presence of functional block in the sinus venosa region but not at the CT. The aim of this study was to define these regions of block in the right atrium using a three-dimensional noncontact mapping system. METHODS AND RESULTS: In 39 AFL patients (33 men and six women, mean age 56 +/- 13 years), a noncontact multielectrode array was used to reconstruct electrograms in the right atrium. Isochronal and isopotential propagation mapping was performed during AFL and during pacing from the coronary sinus ostium and the low lateral wall (cycle length from 600 to 240 msec) in sinus rhythm after creation of isthmus block. A single line of block along the CT area was found in 18 patients (46%). Two lines of block were found in 21 patients (54%), with the first line located along the CT area. The second was located in the sinus venosa region in 20 patients (51%) and in the lateral wall in 1 patient (3%). In all patients, the block in the lower part of the CT was observed during AFL (60%) and during pacing at all cycle lengths (48%-62%). The length and proportion of block were inversely proportional to pacing cycle length. CONCLUSION: Double lines of block were frequently observed in patients with AFL, and both lines may form the posterior boundaries of the AFL circuit. Block was fixed in the lower part of the CT and was functional in the upper part of the CT.

Atrial Flutter↗
PubMed2005

Bundle branch block in alternate beats during 2:1 atrial flutter.

This presentation deals with a case of atrial flutter. During 2:1 A/V conduction, the QRS complexes showed a regular alternation of narrow beats and wide beats with a typical configuration of left bundle branch block. In contrast, pauses resulting from 4:1 A/V conduction ratio always resulted in narrow beats. Disappearance of left bundle branch block with long R-R intervals demonstrated that the block was tachycardia-dependent or phase 3. Analysis of the tracing suggested that narrowing of QRS complexes in alternate beats was due to supernormal left bundle branch conduction associated with retrograde concealed conduction into the anterogradely blocked bundle branch.

Aged↗
PubMed2001

Increased incidence of atrial flutter associated with the rejection of heart transplantation.

Atrial fibrillation (AF) and atrial flutter (Afl) are common dysrhythmias that occur after orthotopic heart transplantation (OHT); however, their etiology and clinical significance have not been defined. To determine the precise incidence of sustained AF and Afl and their association with cardiac rejection, 892 consecutive patients who underwent OHT were studied. A total of 104 patients had 113 episodes of Afl; 102 patients had 117 episodes of AF. The incidence of Afl (12.7%) was the same as AF (13.1%). Sixty-nine AF episodes occurred in first 2 weeks after transplantation, and 22 of which were associated with rejection. In contrast, only 20 Afl episodes occurred the first 2 weeks after OHT, 10 of which were associated with rejection. Fifty-two episodes of Afl occurred during from the third week to 6 months after transplantation, 34 of which were associated with moderate to severe cellular or humoral rejection and/or transplant coronary artery disease (TCAD). All 41 Afl episodes that occurred 6 months after transplantation were associated with cellular and humoral rejection, and/or TCAD. The prevalence of Afl was significantly higher in biatrial than bicaval anastomosis. Atrial conduction defect, manifested by the increase of terminal force of the P wave in lead V(1) of the surface electrocardiogram, predicted the occurrence of Afl and AF associated with rejection in OHT with a sensitivity of 89% and specificity of 92%. These results demonstrate that the incidence of Afl increased after OHT, which might be a consequence of cellular and humoral rejection, and coronary vasculopathy of the transplanted hearts.

Adolescent↗
PubMed1988

[Transesophageal stimulation in the treatment of atrial flutter and tachysystole. Factor influencing immediate results].

The effectiveness and safety of transoesophageal atrial pacing in the treatment of atrial flutter and tachycardia have been well demonstrated. The purpose of this study was to determine the factors that could influence the results of this method at the end of the procedure. Seventy-seven transoesophageal atrial pacings were performed in 62 unselected consecutive patients with either flutter or atrial tachycardia. The following parameters could be evaluated in 55 patients: date of onset of the arrhythmia, echocardiographic diameter of the left atrium, maximum amplitude of oesophageal atrial potentials, voltage and frequency of stimuli in the last stage of pacing. Our results can be summarized as follows: In both flutter and atrial tachycardia taken globally, conversion to sinus rhythm was obtained in 37 p. 100 of the cases, and conversion to atrial fibrillation in 46.7 p. 100 of the cases. The failure rate was 19.4 p. 100; all failures were due to lack of atrial capture during pacing. The main factor or transoesophageal atrial capture is voltage. Patients must be able to tolerate the voltage needed for capture. In the case of flutter, when capture was achieved a normal-sized left atrium and a high maximum amplitude of oesophageal atrial potentials were factors indicating that conversion to sinus rhythm could be expected. This, however, did not apply to atrial tachycardia. -- Whatever the type of tachyarrhythmia, the more recent its onset the easier its reduction.

Adolescent↗
PubMed2006

High-resolution mapping around the eustachian ridge during typical atrial flutter.

BACKGROUND: Although the reentrant circuit of typical atrial flutter (AFL) has been well recognized, the activation around the Eustachian ridge (ER) has not been fully characterized. The aim of this study was to delineate the activation patterns around the ER during typical AFL using high-resolution noncontact mapping. METHODS: Fifty-three patients (M/F = 43/10, 62 +/- 14 years) with typical AFL were included. The high-resolution mapping of the right atrium using a noncontact mapping system during AFL and pacing from the coronary sinus (CS) was performed to evaluate the conduction through the ER. RESULTS: Three types of activation patterns around the ER could be classified according to the ER conduction during AFL and CS pacing. Type I (n = 21, M/F = 16/5, 61 +/- 13 years) exhibited conduction block at the ER during AFL and CS pacing. The local unipolar electrograms at the ER exhibited long double potentials (DPs) (109 +/- 12 ms, range 77-153 ms) during AFL and CS pacing (84 +/- 18 ms, range 48-129 ms). Type II (n = 8, M/F = 7/1, 61 +/- 15 years) exhibited conduction block at the ER during AFL, but conduction through the ER during CS pacing. The unipolar electrograms exhibited long DPs (119 +/- 12 ms, range 97-141 ms) at the ER during the tachycardia and an rS pattern during CS pacing. Type III (n = 24, M/F = 20/4, 61 +/- 16 years) exhibited an activation wavefront that passed along the ER, with the sinus venosa as the posterior barrier during AFL. During CS pacing, all cases exhibited conduction through the ER with an rS pattern. CONCLUSIONS: This study is the first to demonstrate the three patterns of activation along the ER during AFL and CS pacing. This finding suggested that the ER is an anatomic and functional barrier during typical AFL.

Aged↗
PubMed1998

Atrial lead implantation during atrial flutter or fibrillation?

In patients with sinoatrial disease, unexpected atrial flutter (Af) or fibrillation (AF) is a common problem during implantation of atrial-based pacing systems. As an alternative approach to blind atrial lead placement, lead positioning could be optimized by atrial electrogram mapping. It was the object of this study to evaluate if atrial lead implantation according to this approach and during ongoing arrhythmia is reasonable or if it should be postponed until restoration of sinus rhythm (SR). Twenty-nine consecutive patients (group I) with sick sinus syndrome received a dual-chamber pacemaker during an episode of Af (n = 11) or AF (n = 18). All but two atrial leads were of the screw-in type and had bipolar sensing. Atrial lead position was optimized by mapping the electrogram under fluoroscopy to find locations with high potential amplitudes. The patients were followed for 15.1 +/- 9.8 months, and atrial sensing threshold (AST), atrial pulse width threshold (PWT) at 2.0 V, the pacing mode programmed, and the clinical outcome (OUT) were recorded. The control group consisted of 30 patients (group II) who equally had a history of AF or Af, but were in SR during implantation. The atrial peak-to-peak potential (APEAK) after final lead placement was lower for AF (median value 2.5 mV, lower-upper quartile: 1.7-3.1 mV) as compared to Af (3.8 mV, 2.7-4.9 mV, P < 0.05) and SR (4.1 mV, 3.3-6.2 mV, P < 0.001). There was a correlation (P < 0.01) between APEAK during Af/AF and the postoperative AST immediately after restoration of SR. No lead in any group had to be corrected due to improper sensing in the postoperative course. Median chronic AST was 2.8 mV (2.0-4.0 mV) in group I and 4.0 mV (2.8-4.0 mV) in group II. Median chronic PWT at 2.0 V was 0.15 ms (0.12-0.26 ms) in group I and 0.15 ms (0.09-0.20 ms) in group II. There was no significant difference in chronic AST and PWT between both groups. All but two patients in group I preserved SR as the basic rhythm. A stable SR was observed in 10 of 29 patients, intermittent Af/AF was documented in 17 of 29 patients, seven of whom were asymptomatic. There was no significant difference in OUT between group I and II. Hence, sinus rhythm is not a prerequisite of atrial lead implantation. Mapping the Af or AF waves appears to be useful to guide lead placement and to achieve sufficient sensing and pacing conditions after conversion to sinus rhythm.

Aged↗
PubMed1995

Life-threatening alterations in heart rate after the use of adenosine in atrial flutter.

Adenosine has become the preferred treatment for common types of supraventricular tachycardia because it is extremely effective and rarely associated with with serious side effects. It has also been advocated as an intervention for diagnostic use to assess uncommon types of tachycardia. Evidence is shown in this report that adenosine was associated with dangerous worsening of arrhythmia in patients with atrial flutter. In two patients, adenosine precipitated acceleration of ventricular response, in one case necessitating emergent cardioversion. Both patients had atrial flutter with 2 to 1 atrioventricular block that evolved into 1 to 1 atrioventricular conduction. In three other patients, adenosine was associated with prolonged bradyasystole and hypotension. In each of the five patients, adenosine was given in a standard fashion (6 or 12 mg). In summary, adenosine should be recognized as a potentially dangerous intervention in patients with atrial flutter. If it is used for diagnostic purposes, resuscitative equipment should be readily available.

Adenosine↗
PubMed2002

Effects of linear ablation at the isthmus between the tricuspid annulus and inferior vena cava for atrial flutter on autonomic nervous activity: analysis of heart rate variability.

Heart rate is largely affected by the autonomic nervous system. However, little is known about the anatomic pathway of autonomic nerve fibers innervating the sinus node. The present study: (1) evaluates the effects of cavotricuspid isthmus ablation for common atrial flutter (AFL) on autonomic nervous function by using heart rate variability analysis, and (2) investigates the distribution of autonomic nerve pathways innervating the sinus node. Twelve patients with paroxysmal common atrial flutter who maintained sinus rhythm both before and after radiofrequency ablation were selected for the study. Holter ambulatory recordings were performed before and after (2.3 +/- 1.0 days) radiofrequency ablation of cavotricuspid isthmus. Heart rate and time domain (SDANN, rMSSD, pNN50) and frequency domain (low frequency (LF), high frequency (HF), LF/HF) analysis of heart rate variability were compared before and after ablation. Mean heart rate did not change significantly after ablation (59 +/- 6 vs 61 +/- 9 beats/min); parasympathetic indices of heart rate variability (SDANN, rMSSD, pNN50, HF) did not change significantly (110 +/- 37 vs 117 +/- 20 ms; 32 +/- 21 vs 28 +/- 9 ms; 4.8 +/- 0.9 vs 4.7 +/- 0.71n(ms2)); and sympathetic indices of heart rate variability (LF/HF) did not change significantly (1.1 +/- 0.2 vs 1.2 +/- 0.1). Cavotricuspid isthmus ablation for atrial flutter did not significantly change heart rate and heart rate variability because parasympathetic and sympathetic fibers innervating the sinus node are scarce in this region.

Aged↗
PubMed1983

Evidence of a reentry circuit in the common type of atrial flutter in man.

To investigate the mechanism of atrial flutter (AF) in humans, we studied 13 patients during episodes of spontaneous common AF, with simultaneous multiple atrial endocavitary recordings and atrial programmed stimulation. In all patients, low paraseptal atrial activation preceded high right atrial activation, and the latter preceded mid- or low lateral right atrial activation (recorded in five patients). Programmed atrial stimulation resulted in early reset of the AF cycle, with an unchanged poststimulation AF activation pattern. The poststimulation cycle recorded from an even potential to the site of stimulation was always shorter than the basic flutter cycle length. The poststimulation cycle recorded at the site of stimulation was always equal to or longer than the flutter cycle length. These results strongly favor the existence of a reentry circuit to which the extrastimulus has access.

Adult↗
PubMed2003

Conduction velocity around the tricuspid valve annulus during type 1 atrial flutter: defining the location of areas of slow conduction by three-dimensional electroanatomical mapping.

BACKGROUND: Conduction velocity (CV) around the tricuspid valve annulus (TVA) during type 1 atrial flutter (AFL) has been shown to be slowest in the tricuspid valve-inferior vena cava (TV-IVC) isthmus, compared to the septal or free wall segments of the TVA. However, fiber orientation in the triangle-of-Koch suggests that the inferior septum and medial TV-IVC isthmus should be the most slowly conducting segments around the TVA. METHODS: To test this hypothesis we evaluated CV around the TVA during type 1 atrial flutter in 11 patients, using an electro-anatomical mapping system (Carto). CV was first calculated in 4 segments around the TVA including the TV-IVC isthmus, lateral free wall, superior free wall and septum, and then calculated in 8 segments around the TVA including medial (MI) and lateral isthmus (LI), inferior (IL) and superior lateral (SL) free wall, lateral (LS) and medial superior (MS) free wall, and superior (SS) and inferior septum (IS). Statistical comparison of CV from these multiple segments was made by one-way analysis of variance. RESULTS: Measured in 4 segments around the TVA, mean CV (m/sec) in the TV-IVC isthmus (0.81 +/- 0.23) and the septum (0.93 +/- 0.18) was significantly slower than CV in the lateral free wall (1.16 +/- 0.23) and superior free wall (1.10 +/- 0.20), and CV in the TV-IVC isthmus was significantly slower than in the septum (p < 0.05). However, when analyzed in 8 segments, mean CV in the MI (0.56 +/- 0.16) and IS (0.59 +/- 0.24) was significantly (p < 0.05) slower than in all other segments including the LI (1.06 +/- 0.46), IL (1.17 +/- 0.40), SL (1.15 +/- 0.40), LS (1.04 +/- 0.25), MS (1.15 +/- 0.28), and SS (1.26 +/- 0.36) segments. CONCLUSIONS: Consistent with previous reports, CV around the TVA during type 1 AFL was slowest in the TV-IVC isthmus, compared to the septum, superior and lateral free wall regions. However, when the TVA was further subdivided into 8 segments, CV in the MI and IS segments was significantly slower than in all other segments around the TVA. These observations more precisely define the regions of slow conduction in human type 1 AFL, and are consistent with the known anisotropy and slow conduction in the Triangle of Koch.

Anisotropy↗
PubMed1998

Thrombolism with atrial flutter.

These data provide convincing evidence that patients with atrial flutter have a significant thromboembolic risk. Their anticoagulation should be managed in the same manner as patients with atrial fibrillation.

Anticoagulants↗