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PubMed2004

Clinical study of the efficacy of a cooled-tip catheter ablation system for common atrial flutter.

BACKGROUND: Radiofrequency catheter ablation (RF-CA) of common atrial flutter (AFL) requires the creation of a transmural incision to create a bidirectional conduction block in the cavotricuspid isthmus (ITH). METHODS AND RESULTS: RF-CA of the ITH using a cooled-tip system was carried out in 40 patients. In the 'conventional' mode (CONV) of the system, RF energy was applied for 2 min with the temperature set at 60 degrees C and power of up to 50 W, and in the failed cases the 'cooled-tip' mode (COOL) was utilized at 45 degrees C with up to 30 W (with a 15 ml/min saline flow rate). Of the 40 patients, 29 crossed over from the CONV to the COOL after a failed ablation of the AFL. As a result, in all 40 patients a complete linear incision could be created with either the COOL or the CONV, resulting in the successful abolition of the AFL. Complete bi-directional block was successfully created in all patients. No significant side effects occurred. CONCLUSIONS: The COOL was found to be more effective and just as safe as the CONV for AFL ablation, thus facilitating the rapid and complete elimination of the AFL.

Adult↗
PubMed2004

Relationship between anatomic location of the crista terminalis and double potentials recorded during atrial flutter: intracardiac echocardiographic analysis.

INTRODUCTION: The activation sequence in typical atrial flutter (AFL) around the tricuspid annulus is well described. However, activation of the remainder of the right atrium (RA) is not well defined. Previous studies have shown a linear block at the crista terminalis (CT) during AFL. The aim of this study was to evaluate the relationship between the location of the CT and the line of block by intracardiac echocardiography (ICE). METHODS AND RESULTS: Twenty-one patients with typical AFL were included in the study. The ICE imaging catheter (9-French with 9-MHz ultrasound transducer) was advanced to the RA. Under ICE guidance, a 20-pole roving catheter was used to map double potentials (DPs) during AFL, and three-dimensional images of the RA were reconstructed. During counterclockwise (CCW), clockwise (CW) AFL, or both, a line of conduction block manifested by DPs was identified at a septal site adjacent to the CT in 12 patients and in the posteroseptal RA in 9 patients. CONCLUSION: The functional line of block in CCW and CW AFL is localized not at the CT but at the septal edge of the CT or in the posteroseptal RA.

Action Potentials↗
PubMed2001

[Atrial flutter: a possible early sign of acute rejection in heart transplantation. A case report].

The authors report the case of a cardiac transplant patient with a recurrence of atrial flutter two months after electrical cardioversion and despite long-term preventive treatment with amiodarone. Early investigation for signs of rejection with 4 endomyocardial biopsies was negative. Aggravation of the haemodynamic status due to flutter with a rapid ventricular response led to an attempted radio-frequency ablation. Endocavitary mapping confirmed persistence of sinus activity in the native atrium and the presence of a circuit of type I isthmic flutter (anticlockwise circuit) in the donor atrium. Ablation by radio-frequency in the same procedure was successful. A fifth myocardial biopsy the same day finally confirmed stage 3A acute rejection. No signs of recurrent rejection or arrhythmia have been observed after 24 months' follow-up in this patient. This preliminary experience confirms the need to look for graft rejection by repeated myocardial biopsies in cardiac transplant, patients with atrial flutter and the efficacy of radio-frequency ablation in cases of resistance to conventional therapy.

Atrial Flutter↗
PubMed1994

[Permanent atrial resynchronization by synchronous bi-atrial pacing in the preventive treatment of atrial flutter associated with high degree interatrial block].

UNLABELLED: Interatrial conduction block results in a very delayed and retrograde activation of the left atrium and is associated with a high incidence of atrial tachyarrhythmias, especially a particular (and specific) form of atypical atrial flutter. Electrophysiologic studies have suggested that these arrhythmias were usually due to reentry and could be directly related to the conduction disturbances in the atrium. If so, we can expect reasonably that permanent atrial resynchronization resulting from simultaneous pacing in different target sites in the atria, may not only correct for interatrial dysynchrony, but also may significantly contribute to prevent arrhythmia recurrences. Twenty-eight patients, mean age 68 years, were included. The mean P wave duration in spontaneous sinus rhythm was 181 +/- 28 ms. In all patients, many recurrences of atrial tachyarrhythmia were documented, especially a specific form of atypical atrial flutter. Medical therapy was constantly ineffective. Three different pacing modes were used: 6 patients, with normal A-V conduction were implanted with a SSI device, programmed in AAT mode and connected, using a Y bifurcated connector, to two atrial leads, one positioned in the right atrium, the second one into the coronary sinus-in 14 patients, with A-V conduction defects, a conventional DDDR unit was implanted and connected to a composite biatrial electrode and a ventricular lead. In that configuration atrial resynchronization was only effective on paced atrial cycles -a specific DDD Chorus ELA Medical device with a special algorithm loaded into the RAM memory was implanted in 14 patients (8 new indications, and 6 patients first implanted with a DDDR unit). RESULTS: during sinus rhythm atrial resynchronization induced a reduction of the P wave duration from 181 +/- 28 ms to 116 +/- 12 ms. During permanent pacing the mean value decreased from 209 +/- 38 ms to 108 +/- 13 ms. During follow-up (34 +/- 15 months) arrhythmia prevention was assessed by history, by monthly surface ECG's and by bimonthly 24 hours Holters recordings and telemetric interrogation of the pacemaker statistics. Twenty-one patients did not experienced any recurrence of arrhythmia. One to three recurrences occurred in the other seven patients, including six patients implanted with a conventional DDDR unit. These preliminary results seem validate the new concept of atrial resynchronization for prevention of atrial arrhythmia associated with interatrial conduction block.

Adult↗
PubMed2006

Paradoxical undersensing during atrial flutter: what is the mechanism?

A patient with congenital complete heart block underwent implantation of a dual-chamber pacemaker. He presented to the emergency room with fatigue and was found to be in atrial flutter. Device interrogation revealed undersensing of 5 mV flutter waves at a programmed sensitivity of 0.5 mV. Due to undersensing, mode switch did not occur. This case illustrates apparently paradoxical undersensing of atrial flutter waves by a dual-chamber pacemaker and can be explained by a phenomenon known as "quiet timer blanking."

Adult↗
PubMed2005

Efficacy and safety of ibutilide for cardioversion of atrial flutter and fibrillation in patients receiving amiodarone or propafenone.

AIM: The effectiveness and safety of ibutilide (IB) use in patients receiving amiodarone or propafenone for atrial flutter (AFL) and atrial fibrillation (AF) were compared to IB alone. METHODS AND RESULTS: In 104 consecutive patients with AF (65%) or AFL (35%), receiving amiodarone (n = 46), propafenone (n = 30), or no specific antiarrhythmic drug (n = 28), IB was given for cardioversion. Fifteen patients in amiodarone group were loaded with 1.2 g intravenously before IB administration. The mean duration of arrhythmia episode was 23 +/- 65 days, while 85% of patients had structural heart disease. The left ventricle ejection fraction was 57 +/- 10% and the left atrium size was 4.2 +/- 0.6 cm. The conversion efficacy did not differ among groups (62% for amiodarone vs 55% for propafenone vs 64% for IB alone). The QTc intervals were significantly prolonged, at 10 minutes and 30 minutes after IB administration, in amiodarone group (from 449 +/- 88 to 496 +/- 92 ms, 508 +/- 52 ms; P = 0.001) and in the group where IB was used alone (from 434 +/- 45 to 517 +/- 74 ms, 492 +/- 65 ms; P < 0.001), while it remained unchanged in propafenone group (from 464 +/- 52 to 471 +/- 80 ms, 489 +/- 93 ms; P = 0.536). The only predictor of conversion was the presence of AFL (P = 0.009). Five patients developed ventricular tachycardias after IB administration (two in propafenone, one in amiodarone, and two in IB group). CONCLUSIONS: The use of IB in patients receiving amiodarone or propafenone for AFL or AF is equally effective and safe as the use of IB alone. The presence of AFL is the stronger predictor factor for cardioversion.

Adult↗
PubMedDate not supplied

[Radical surgical treatment of atrial flutter].

From January 1983 to May 1992 a total of 40 patients with a tachysystolic type of atrial flutter (AF) refractory to preventive antiarrhythmic therapy were examined and operated on. The obligatory stage of a preoperative examination was invasive phonoelectrocardiography. The effects of "entrainment" and adaptation of refractory periods of various portions of atria were estimated depending on the duration of a basic stimulation cycle. In inducing a AF paroxysm, the site of early A spike appearance was determined and endomyocardial mapping was performed. During intraoperative mapping, the data on low-amplitude and fragmented activity were processed by a computer. The sequence of the electric activation of the atria in AF was also determined. Twenty seven transthoracic operations were performed via extracorporeal circulation, 9 of them underwent laser or cryogenic isolation of the atrioventricular node, 4 laser photo ablation, 10 cryodestruction of arrhythmogenic areas. Resection of 1/3 of the marginal crust, sinoatrial node with subsequent implantation of a pacemaker was made in 1 patient in the AA1 mode. Three patients underwent operation to create a labyrinth by J. Cox and a corridor by J. Quiraudon. The closed heart operations involved both transvenous electrodestruction of arrhythmogenic areas (5 patients) and destruction of the His bundle with developed complete block and pacemaker implantation in the VVI mode (8 patients). The best results of surgical treatment were obtained in young patients with idiopathic AF (Type 1), when the areas of fragmented and low-amplitude activity could be accurately determined.

Adolescent↗
PubMed1997

P-wave morphology during right atrial pacing before and after atrial flutter ablation--a new marker for success.

Fourteen patients with typical atrial flutter underwent pacing from the low lateral right atrium and the proximal coronary sinus in normal sinus rhythm before and after catheter ablation. During low lateral right atrial pacing, a positive change in P-wave morphology in the inferior leads was noted in every patient (n = 12) in whom bidirectional block was achieved; no recurrence was noted in any of these patients.

Aged↗
PubMed2002

Macroreentrant atrial flutter around a common atrioventricular canal in an infant with complicated congenital heart anomaly.

This report describes a 2-year-old male infant after repair of complicated congenital heart anomalies including common atrioventricular canal (CAVC), in which macroreentrant atrial flutter around the CAVC was demonstrated by electroanatomic mapping (CARTO) using a single catheter. Radiofrequency catheter ablation at the isthmus between the CAVC and the inferior vena cava eliminated the atrial flutter successfully.

Atrial Flutter↗
PubMed2000

Early cardioversion of atrial fibrillation and atrial flutter guided by transoesophageal echocardiography: a single centre 8.5-year experience.

AIMS: To analyse the safety and impact on maintenance of sinus rhythm of transoesophageal echocardiographically guided early cardioversion associated with short-term anticoagulation in a large series of patients with atrial fibrillation and atrial flutter. METHODS AND RESULTS: Patients who were candidates for cardioversion were eligible for inclusion if they had atrial fibrillation or atrial flutter lasting longer than 2 days or of unknown duration. Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echocardiography followed by transoesophageal echocardiography. Early cardioversion was performed if no thrombus was seen on the transoesophageal study. Warfarin was maintained for 1 month after cardioversion. In patients with atrial thrombi, cardioversion was deferred and prolonged anticoagulation was prescribed. The study population included 183 patients. One hundred and sixty nine patients without atrial thrombi underwent early cardioversion. Fourteen patients with atrial thrombi (7.6%) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin, and cardioversion was performed if clot regression was documented. No patient in our study population had a clinical thromboembolic event at 1 month follow-up (95% C.I. 0-0.016). The immediate success rate of cardioversion was better among patients with atrial fibrillation < 4 weeks duration compared with patients with atrial fibrillation of longer or of unknown duration: 96.6% vs 85%, respectively (P = 0.014). At 1 month follow-up, the percentage of arrhythmia relapses in patients with initially successful cardioversion was similar in the two groups (29% vs 26%, P = ns); thus the initial better outcome in patients with recent-onset arrhythmia was not lost. CONCLUSION: Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe. This approach permits abbreviation of the overall duration of atrial fibrillation and has a better impact on the maintenance of sinus rhythm for patients in whom the duration of atrial fibrillation is < 4 weeks.

Adult↗
PubMed1998

[Catheter ablation of atrial flutter. Electrophysiological characterization of posterior and septal isthmus block].

PURPOSE: Evaluate the different types of conduction blocks obtained between inferior vena cava-tricuspid annulus (posterior isthmus) and between tricuspid annulus-coronary sinus ostium (septal isthmus) after radiofrequency (RF) catheter ablation of atrial flutter (AFL). METHODS: In 16 procedures, 14 patients (pts), 9 male, with type I AFL underwent RF ablation. Atrial activation around tricuspid annulus was performed with a 10-bipole "Halo" catheter (H1-2; H19-20). In sinus rhythm, isthmus conduction was evaluated during proximal coronary sinus (PCS) and low lateral right atrium (H1-2) pacing, before and after linear ablation. According to the wave front of impulse propagation we assessed absence of block (bidirectional conduction); incomplete block (bidirectional conduction with delay in one front of impulse propagation) and complete block (absence of conduction). The PCS/H1-2 interval was measured before and after ablation. RESULTS: Complete isthmus block was achieved in 7 (44%) and incomplete block in 4 (25%) procedures. Conduction block was not achieved in 5 procedures. At a mean follow-up of 12 months, there were no recurrences in the pts with complete block, whereas AFL recurred in the 6 pts with incomplete or no conduction block (p < 0.001). Pts with complete block had delta PCS/H1-2 interval (74.0 +/- 26.0 ms) greater than incomplete (30.5 +/- 7.5 ms) or absent block (p < 0.05). CONCLUSION: The verification of complete isthmus conduction block with atrial multipolar mapping is an effective strategy to assess electrophysiological success and absence of late recurrence in common atrial flutter ablation.

Adolescent↗
PubMed2001

Syncope in patients with atrial flutter during treatment with class Ic antiarrhythmic drugs.

We describe 2 atrial flutter (AFL) patients with syncope during treatment with class Ic antiarrhythmic drugs. During the syncope, 1:1 atrioventricular (AV) conduction during AFL preceded a wide QRS tachycardia. The class Ic drugs, flecainide and pilsicainide, slowed the atrial rate, resulting in AFL with 1:1 AV conduction, and the width of the QRS complexes became wider during the tachycardia. Syncope was abolished after successful radiofrequency catheter ablation of the AFL. These potential proarrhythmic effects of the class Ic drugs should be taken into account in AFL patients, and concomitant use of beta-blocking agents would be critical to prevent proarrhythmias.

Adult↗
PubMed2006

Success rate of catheter ablation in atrial flutter: comparison of a 4- or 5-mm tip electrode catheter with an 8-mm tip electrode catheter.

BACKGROUND: Radio frequency (RF) energy is capable of interrupting the reentrant circuit of atrial flutter and curing the arrhythmia. The development of 8-mm tip catheter provides more tissue damage and has offered the promise of improved success. The purpose of our study was to determine if the acute and long-term success with the 8-mm tips were superior to the 4- or 5-mm tips. MATERIALS AND METHODS: The outcomes of the first 20 patients in whom an 8-mm tip catheter was used were compared with the previous 20 patients in whom a 4-or 5-mm tip catheter was used. Procedural (acute) ablation success was defined by creation of bi-directional isthmus block. Long-term success was defined as the prevention of clinically evident atrial flutter (AFl) as determined by the absence of symptoms or maintenance of sinus rhythm on electrocardiogram, six months to one year after the procedure. RESULTS: Compared to the 4- or 5-mm tip, the 8-mm catheter tip was associated with a reduced ablation duration {22.3 +/- 16 versus 11.5 +/- 5 min (p = 0.0078)}, a lower mean number of ablations {13.5 +/- 9.9 versus 6.8 +/- 2.9 (p = 0.0065)} and a reduced procedure time {1.8 +/- 0.7 versus 1.1 +/- 0.5 h (p = 0.0032)}. Acute success was 95% in the 4- or 5-mm group versus 80% in the 8-mm group (p = NS), but long-term success was higher in the 8-mm group than the 4- or 5-mm group (87.5 versus 63.2%, p = 0.0436). CONCLUSIONS: Eight-millimeter tip catheters for AFl shorten procedure time, reduce the duration and number of ablations and accomplish bi-directional block when compared with smaller tipped catheters. The long-term success rate is better with the 8-mm tips and should be the preferred catheter for RF ablation of AFl.

Aged↗
PubMed1997

Symptomatic improvement after AV nodal ablation and pacemaker implantation for refractory atrial fibrillation and atrial flutter.

Symptomatic Improvement was evaluated in 64 patients with drug-refractory atrial fibrillation or atrial flutter who underwent atrioventricular (AV) nodal ablation and permanent pacemaker implantation. The arrhythmias were chronic in 40 patients and paroxysmal in 24 patients. All were refractory to multiple drugs (3.7 +/- 1.5) and had severe symptoms: palpitations (58 patients), dyspnea (n=58), dizziness (n=38), asthenia (n=37), and chest pain (n=20). All underwent AV nodal ablation and single- (n=39) or dual-chamber (n=25) pacemaker implantation. During follow-up of 20.4 +/- 17.8 months, palpitations improved in 100% of 58 patients who had palpitations before the ablation, dyspnea improved in 75% of 58 patients, chest pain in 95% of 20 patients, asthenia in 75% of 37 patients, and dizziness in 93% of 38 patients. Moderate to significant improvement in these symptoms was reported in 83% of patients and mild improvement in 5%. Before ablation, 77% of patients were in New York Heart Association functional class III or IV. After ablation, 19% of patients were in the same functional classes (P < 0.05). Thus, AV nodal ablation and pacemaker implantation in patients with drug-refractory atrial fibrillation or flutter was associated with significant improvement in presenting symptoms and functional capacity. A randomized, controlled study is needed to compare this form of therapy with other therapeutic modalities.

Aged↗
PubMed1986

[Prevention of atrial flutter with Chinidin retard].

The action of the preparation Chinidin retard, tablets of 0.250, was studied with a view to its effects of preserving the recovered sinus rhythm after regularization in 32 patients with atrial flutter, as well as its effect on central hemodynamics and functions of parenchymal organs. The successful anti-recurrence treatment and the maintenance of lasting sinus rhythm after regularization in 90.6 per cent of the patients for more than 6 months with only 2 tablets daily, provided grounds to recommend chinidin retard as an agent of choice for long-term prophylaxis against the paroxysm of atrial flutter. The preparation has a lightly manifested negative inotropic action, but with the doses administered--it leads to no left-ventricular dysfunction. The long-term treatment with chinidin retard has no toxic effect on parenchymal organs.

Atrial Flutter↗
PubMed1990

[The potentials for curing atrial flutter by the combined use of transesophageal electrical stimulation and anti-arrhythmia preparations].

Potentialities of the recovery of the sinus rhythm were studied in 21 patients with atrial flutter (AF) using frequent transesophageal electric cardiac pacing (TEEP) per se and after intravenous injection of ritmilen and novocainamide under outpatient conditions. TEEP made it possible to arrest AF in 24% of patients and to transform flutter into steady atrial fibrillation in 48% of patients. In 28% of cases, the pacing turned out ineffective. Subsequent administration of antiarrhythmic drugs made the rhythm return to normal in 24% of patients, whereas repeated TEEP conducted after drug administration in additionally 33% of patients. The efficacy of frequent TEEP combined with administration of ritmilen and novocainamide amounted to 81%.

Adult↗
PubMed1992

Frequency and implications of resetting and entrainment with right atrial stimulation in atrial flutter.

Thirty-three patients (24 with typical and 9 with atypical flutter-wave morphology) were studied to evaluate the incidence and implications of resetting and entrainment of atrial flutter with right atrial stimulation. Resetting with single extrastimulus was present in 23 cases (group A) and absent in 10 (group B). Most cases of reset flutter were typical (20 of 23). Fixed fusion indicative of entrainment was observed in all 29 cases with pacing trains. Groups A and B did not differ significantly in flutter cycle length (230 +/- 20 vs 223 +/- 19 ms), atrial functional refractory period (165 +/- 18 vs 167 +/- 22 ms) or longest paced cycle length producing entrainment (213 +/- 19 vs 210 +/- 19 ms). In contrast, the return cycle after the longest paced cycle length producing entrainment was significantly shorter in group A (228 +/- 27 vs 284 +/- 56 ms; p = 0.001). The return cycle in group A was virtually identical to the flutter cycle length, whereas in group B it was greater (p = 0.002 compared with group A). Resetting was more frequent in typical than atypical flutter (20 of 24 vs 3 of 9; p = 0.01). Both typical and atypical flutter can be transiently entrained by right atrial pacing. Lack of resetting and longer return cycle, suggesting a longer conduction time between the reentrant circuit and the stimulation site, were mostly observed in atypical flutter. The data suggest a different location for both types of flutter, and may have implications for ablation techniques. A more cautious approach, with more extensive mapping, appears appropriate for ablation attempts of atypical flutter.

Adult↗