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PubMed1983

Fourier analysis of a gated blood-pool study during atrial flutter.

First-harmonic Fourier analysis of a gated blood-pool study is based on the assumption that the cardiac chambers contract once per cardiac cycle. In atrial arrhythmias this condition may not exist for the atria. We recently studied a patient with atrial flutter and 2:1 atrioventricular conduction. There were predictable alterations in the first-harmonic Fourier phase and amplitude images. The observed changes from first-harmonic Fourier analysis were: (a) very low atrial amplitude values, and (b) absence of identifiable atrial regions on the phase image.

Aged↗
PubMedDate not supplied

Atrial flutter following a wasp sting.

Wasp stings have been associated with a wide variety of local and systemic reactions including, rarely, tachyarrhythmias. We discuss a case of atrial flutter occurring in a 64-year-old man following a single sting in the absence of anaphylaxis. The pathogenesis is discussed and the literature reviewed.

Animals↗
PubMed2004

Pattern of isthmus conduction recovery using open cooled and solid large-tip catheters for radiofrequency ablation of typical atrial flutter.

INTRODUCTION: Open cooled-tip and solid 8-mm-tip catheters have demonstrated safety and effectiveness for radiofrequency current (RFC) ablation of typical atrial flutter (AFL). However, data from prospective and randomized studies in this setting are lacking. METHODS AND RESULTS: One hundred thirty consecutive patients (104 men; 61 +/- 11 years) with AFL were randomized to undergo RFC catheter ablation either using a solid 8-mm-tip catheter (group A, 65 degrees C, 70 W, 60 s) or an open irrigated-tip catheter (group B, 65 degrees C, 50 W, 60 s, 17 mL/min flow). Endpoint was bidirectional conduction isthmus block. In cases of repeated (two times) transient isthmus block, the catheter was changed (crossed over) to the catheter used in the other randomization arm, but patients remained in the original group following intention-to-treat analysis. The selected endpoint could be achieved in all patients after 12 +/- 6 RFC pulses in group A and 10 +/- 7 RFC pulses in group B (P = 0.11). Procedure times were longer (159 +/- 38 min vs 138 +/- 37 min, P = 0.002) and x-ray exposures higher in group A (fluoroscopy time 25 +/- 17 min vs 21 +/- 10 min, P = 0.08; x-ray dosage 3,133 +/- 2,576 cGy.cm2 vs 2,326 +/- 1,405 cGy.cm2, P = 0.03). Transient isthmus block was observed in 23 group A patients and 12 group B patients (P = 0.03). Onset time of transient isthmus block ranged from 0.5 to 27 minutes. Repeated transient isthmus block occurred in 8 of the 23 patients in group A after 19 +/- 3 RFC applications. After crossover to the cooled-tip catheter, the endpoint was reached another 5 +/- 1 RFC pulses. In group B, all patients could be treated without change of ablation catheter. After a follow-up of 14 +/- 2 months, 2 patients (3%) in group A and 1 patient (1.5%) in group B presented with AFL recurrence. CONCLUSION: Open cooled-tip catheters are more effective than solid large-tip catheters for AFL ablation. The greater effectiveness is evident in cases showing repeated conduction recovery within the cavotricuspid isthmus. Primary use of open irrigated-tip catheters should be considered for AFL ablation.

Atrial Flutter↗
PubMed2006

Cavotricuspid isthmus angiography predicts atrial flutter ablation efficacy in 281 patients randomized between 8 mm- and externally irrigated-tip catheter.

AIMS: Radiofrequency ablation (RFA) of cavotricuspid isthmus (CTI)-dependent atrial flutter can be performed using various types of ablation catheters. Recent evaluations comparing externally cooled-tip RFA (ecRFA) catheters and large-tip (8 mm) catheters found that ecRFA catheter may have a higher efficacy for CTI ablation. The aim of this prospective study was to compare both catheters by stratifying on CTI morphology in order to explain, in part, the discrepancies between previous randomized studies, and to validate predictive factors of difficult CTI ablation on clinical, echocardiographic, and angiographic data. METHODS AND RESULTS: Over a period of 24 months, 281 patients were included and stratified on CTI morphology: 'straight', 'concave', and 'pouch-like recess'. In straight CTI (n=150), the duration of application time with a median of 6 min [interquartile range (IQR) 4-9] vs. a median of 12 min (IQR 16-19; P<0.0001) and the duration of X-ray exposure with a median of 6 min (IQR 4.4-9.7) vs. a median of 10.4 min (IQR 7-17; P<0.0001) were significantly lower with an 8 mm-tip when compared with ecRFA catheter. In contrast, in concave CTI (n=95), a trend towards both shorter application time with a median of 12.5 min (IQR 6-23) vs. a median of 19 min (IQR 7-28; P=0.08) and X-ray duration exposure with a median of 10.4 min (IQR 6-20) vs. a median of 13 min (IQR 8-24; P=0.08) with an ecRFA catheter when compared with 8 mm-tip catheter were evidenced. No significant difference was shown between 8 mm-tip and ecRFA catheters in the pouch-like recess group (n=36). Predictive factors of difficult ablation include right CTI length and morphology. CONCLUSION: This study demonstrates that the 8 mm-tip catheter is more effective for ablation in case of a straight angiographic isthmus morphology and that the ecRFA catheter tends to be more effective in case of concave angiographic isthmus morphology. Thus, angiographic isthmus evaluation may predict both the effectiveness of an RF catheter, and the risk of an expensive crossover. These data may explain, in part, the discrepancies of previous studies comparing both catheters.

Aged↗
PubMed1993

Circus movement atrial flutter in the canine sterile pericarditis model. Cryothermal termination from the epicardial site of the slow zone of the reentrant circuit.

BACKGROUND: We have shown that atrial flutter (AF) in dogs with sterile pericarditis is commonly due to a single-loop reentrant circuit in the lower right atrium comprised of a functional or functional/anatomic obstacle and a slow zone of conduction (SZ) between the central obstacle and the atrioventricular (AV) ring. The goals of the present study were 1) to establish that the epicardial SZ is the critical component of circus movement AF and 2) to identify the optimal site within the epicardial SZ at which interruption of circus movement can be accomplished by ablative techniques. METHODS AND RESULTS: We analyzed the atrial activation patterns during epicardial cooling of the SZ with as N2O-cooled probe in eight dogs (five with clockwise [CW] reentrant circuit, one with counterclockwise [CCW] reentrant circuit, and two with both CW and CCW reentrant circuits around the same pathway). In all eight dogs, cooling (-5 to +5 degrees C for 5-20 seconds) the narrow isthmus at the inferoposterior part of the SZ between the central obstacle and the AV ring reversibly terminated the reentrant circuit, whereas cooling outside this area failed to terminate the reentrant circuit. The circus movement was not observed to continue along alternate pathways when conduction in this critical zone was interrupted. Both CW and CCW reentrant circuits could be terminated from the same site within the SZ. Cooling resulted in slowing of conduction in the SZ (55 +/- 15 msec) in both CW and CCW reentrant circuits. Cooling-induced termination of CW reentrant circuits was characteristically associated with oscillations of conduction in the cooled zone of the last three cycles before termination and conduction block occurred within the cooled zone. The last "manifest" reentrant cycle was associated with the longest conduction delay in the cooled zone. However, this delay was not necessarily reflected in the length of the last reentrant cycle because of compensatory acceleration of conduction in the rest of the pathway. On the other hand, in CCW reentrant circuits, conduction block occurred abruptly at the distal border of the SZ and without significant oscillations of conduction. CONCLUSIONS: The present study provides convincing evidence that single-loop circus movement in this model is critically dependent on an obligatory conduction in a SZ in the inferoposterior portion of the free right atrial wall between a functional obstacle and the AV ring. Because the atrial myocardium behaves electrophysiologically as a two-dimensional surface, the results of this study may help to guide the endocardial electrode catheter ablative technique for treatment of clinical AF.

Animals↗
PubMed2000

Ablation of atypical atrial flutter guided by the use of concealed entrainment in patients without prior cardiac surgery.

INTRODUCTION: Mapping techniques have not been systematically evaluated with respect to atypical atrial flutter (AF) not involving the inferior vena cava isthmus. The purpose of this study was to assess prospectively the use of concealed entrainment (CE) in mapping of AF and to assess the clinical benefit of ablation of clinically relevant atypical AF. METHODS AND RESULTS: In seven consecutive patients without prior cardiac surgery presenting with atypical AF, mapping was performed in the right and, if necessary, left atrium. At sites with CE, radiofrequency energy was delivered. In a posthoc analysis, the endocardial activation time, stimulus-flutter wave (F) interval, presence of split potentials and diastolic potentials, and postpacing interval were assessed, and effective sites were compared to ineffective sites. A total of 22 forms of atypical AF either could be induced or were present at the time of the study. Eleven of the 13 targeted atypical AFs (85%) were successfully ablated. The positive predictive value of CE increased from 45% to 75% in the presence of matching electrogram-F and stimulus-F intervals or if flutter terminated during entrainment pacing, and to 88% in the presence of split atrial electrograms or diastolic potentials. During short-term clinical follow-up, none of the patients had recurrence of the ablated AF. However, the majority of patients required either medication for atrial fibrillation or repeated interventions for new forms of AF. CONCLUSION: Mapping and ablation of atypical AF is feasible if sites with CE can be identified. However, the clinical benefit of successful ablations in patients with atypical flutter appears to be limited.

Adult↗
PubMed2005

3-dimensional mapping and radiofrequency ablation of atrial flutter in a patient with interrupted inferior vena cava.

The presence of isolated interrupted inferior vena cava (IVC) is very rare. Though the occurrence of typical atrial flutter in this setting has recently been described, the use of 3-dimensional activation mapping to aid the management of such patients has not yet been described. We report the successful ablation of this arrhythmia in a 63-year-old woman using the superior route through the internal jugular vein with the help of a mapping system.

Atrial Flutter↗
PubMed1996

[Catheter ablation of atrial flutter and fibrillation].

The knowledge of the anatomic and functional bases of common flutter circuits has allowed the definition of an anatomic isthmus, between the inferior vena cava and the tricuspid valve, where radiofrequency application can interrupt the circuit. Some atypical flutter circuits are identical to common flutter circuits, but for an inverted rotation (clockwise), and these can be also ablated in the same isthmus. In cases of flutter (or reentrant tachycardia) due to surgical scars in the atrium, mapping supported with programmed stimulation, can define anatomic isthmuses, where ablation can also interrupt the circuit. There is still no definition of left atrial flutter circuits, that may guide ablation in these cases. Atrial fibrillation ablation is still in its infancy. Some initial experiences have tried to reproduce the division of atrial myocardium as in the maze procedure, and fibrillation was interrupted in a number of patients, submitted to very long procedures. There is still no clear definition of the muscular anatomy of the left atrium, in relation with the fibrillatory process, to guide the design of effective ablation lines. There are also technical problems to produce continuous, transmural ablation lines, that are not arrhythmogenic by themselves. The wide clinical application of ablation to treat atrial fibrillation is still in the distant future.

Atrial Fibrillation↗
PubMed1999

Neonatal atrial flutter following fetal exposure to vibroacoustic stimulation.

The use of vibroacoustic stimulation (VAS) has become a common modality for testing fetal well being. A case of neonatal atrial flutter, following fetal exposure to VAS is presented. It should be emphasized that although VAS is a common and reliable test for evaluating fetal status, complications may occur.

Acoustic Stimulation↗
PubMedDate not supplied

Hemodynamic changes during cardioversion in utero: a case report of supraventricular tachycardia and atrial flutter.

Two cases of fetal tachyarrhythmias were treated in utero. One case showed supraventricular tachycardia which was successfully treated with procainamide. The other case was an atrial flutter with 2:1 atrioventricular conduction (AVC) which was treated with digoxin and verapamil. In both cases, the blood flow in the descending aorta was observed using pulsed Doppler ultrasound during therapy. In the first case, the interval of blood flow peaks was suddenly prolonged to normal heart rate, and in the second case, the blood flow peaks appeared irregularly which indicated that (AVC) was intermittently blocked. The blood flow pattern represented the mode of cardioversion. The blood flow velocity was also measured in both cases; it decreased transiently during therapy representing a depression in cardiac function. The cause of this was thought to be the negative inotropic effects of procainamide and verapamil. In spite of these negative inotropic effects, a greater R-R interval means a greater stroke volume. This relationship has a favorable effect on the fetal circulation as a result of therapy for fetal tachyarrhythmias.

Adult↗
PubMed1998

Radiofrequency catheter ablation for atrial flutter following orthotopic heart transplantation.

A 26 year old woman with a diagnosis of limb girdle muscular dystrophy and peripartum cardiomyopathy underwent orthotopic heart transplantation using standard atrial anastomoses. Recurrent atrial flutter was demonstrated in the absence of histological evidence of cellular rejection. Radiofrequency ablation of the flutter circuit was successfully performed allowing the avoidance of long term antiarrhythmic therapy. Ten weeks following ablation and cessation of amiodarone, presyncopal symptoms were found, associated with daytime and nocturnal sinus pauses of 2.9 seconds and 4.2 seconds, respectively. There was no evidence of AV node conduction impairment. In view of the continued absence of cellular rejection and the evident denervated state of the heart, the pauses reflected significant donor sinus node dysfunction; therefore, an AAIR permanent pacing system was implanted. At the time of pacemaker implantation atrial pacing at 150 beats/min did not produce significant PR interval prolongation or AV block. This case serves to advise rigorous follow up in such patients to continue to seek evidence of sinus node dysfunction potentially requiring permanent pacemaker implantation.

Adult↗
PubMed2002

Acute resumption of conduction in the cavotricuspid isthmus after catheter ablation in patients with common atrial flutter. Real-time evaluation and long-term follow-up.

AIMS: Cavotricuspid isthmus conduction (CIC) is closely associated with the maintenance and recurrence of common atrial flutter (AFL). This study systematically sought to assess the prevalence and characteristics of acute CIC recovery during AFL ablation and to define its predictors and its relationship with the results of long-term follow-up. METHODS AND RESULTS: A total of 124 consecutive patients (105 men, 19 women, mean age 58 +/- 11 years) who underwent successful AFL ablation were included. The procedure endpoint was defined as complete bi-directional CIC block. During an observation period of 30 min, the incidence of CIC restoration was 34.% in patients and 39.8% in applications. It increased with increasing block time and decreased over time during the observation period. Block time in successful burns followed by persistent block was shorter than in those followed by CIC resumption (12 +/- 6 vs 33 +/- 12 s, P<0.0001). A negative correlation between block time and resumption time was found (r = - 0.57, P<0.001). Patients with permanent pacemakers had a higher incidence of acute CIC resumption than those without pacemakers (5/7 vs 29/117, P = 0.007). The AFL recurrence rate was 4.8% during a mean follow-up period of 21 +/- 8 months. Our results suggest that acute CIC resumption may be a potential risk for clinical AFL recurrence during long-term follow-up. CONCLUSIONS: Acute CIC resumption in common AFL ablation varies in terms of incidence and time course. Block time has a predictive value for acute CIC recovery. Observation time can be shortened if block time is short. With longer block time, it is essential to observe for a longer period in order to minimize CIC resumption.

Atrial Flutter↗
PubMed1999

Microwave ablation of atrial flutter.

Radiofrequency (RF) ablation of the isthmus between the inferior vena cava and the tricuspid ring has proven to be a safe and successful method of treating atrial flutter (AF). However, RF ablation lesions are small in size requiring a considerable number of energy applications to ablate the AF circuit. The aim of this study was to evaluate the feasibility and efficacy of microwave energy for AF ablation. We report a case of sustained typical AF treated successfully and safely by 1 pulse of microwave (MW) energy. This showed it is possible to treat AF with a small number of pulse applications.

Atrial Flutter↗
PubMed2003

Rate-dependent slow conduction velocity in the cavo-tricuspid isthmus and septum in patients with atrial flutter.

PURPOSE: To evaluate and compare the effects of heart rate on conduction velocity in the cavotricuspid isthmus (CTI) and septum in patients with and without typical atrial flutter (AF) using electro-anatomic mapping (EAM) of the right atrium (RA). METHODS: Ten patients (age 53+/-10 yrs, 7M/3F) with AF and 13 patients (age 51+/-11 yrs, 5M/8F) with atrioventricular nodal reentrant tachycardia (AVNRT) underwent conventional electrophysiological study, electro-anatomic mapping and radiofrequency ablation. Using EAMs obtained during coronary sinus pacing at pacing cycle length (PCL) 600 ms, 400 ms, and 300 ms, we evaluated conduction velocities in the CTI and septum of RA in 10 patients with AF and compared EAMs to 13 patients with AVNRT to determine whether the conduction slowing required to maintain AFL was related to changes in volume alone or altered RA electrophysiology. RESULTS: Conduction velocities in CTI and septum were significantly slower at all PCL when AF was compared to AVNRT (*P<0.05). Additionally, in the AF group, septal conduction velocities were slower at PCL 600 ms and 400 ms, but not at 300 ms compared to CTI (*P<0.05). In AF, during PCL 300, conduction in CTI slowed significantly compared to PCL 600 and 400 ms such that there was no difference between CTI and septum at PCL 300. CONCLUSIONS: There is slower conduction in the septum compared to the CTI in all patients. However, in patients with AF, there is significant slowing of conduction in the CTI and septum as well as decremental rate-dependent slowing of conduction in the CTI. These findings indicate that in addition to RA enlargement, changes in atrial electrophysiology distinguish AF patients from patients with AVNRT.

Adult↗
PubMed2004

Functional characterization of the crista terminalis in patients with atrial flutter: implications for radiofrequency ablation.

OBJECTIVES: The aim of the study was to investigate the conduction properties and anisotropy of the crista terminalis (CT) in patients with atrial flutter (AFL) using non-contact mapping. BACKGROUND: The CT is a posterior barrier during typical AFL. However, the CT has transverse conduction capabilities in patients with upper loop re-entry (ULR). METHODS: Twenty-two patients (16 males, 63 +/- 15 years) with typical AFL and ULR were included. Non-contact mapping of the right atrium during AFL and pacing from coronary sinus (CS) and low anterolateral right atrium (LARA) was performed to evaluate transverse conduction across the CT. During ULR, the longitudinal (CV(L)) and transverse (CV(T)) conduction velocity along and across the CT were measured. The width of the CT conduction gap was evaluated to guide radiofrequency ablation (RFA). RESULTS: No transverse CT gap conduction was found during typical AFL. Transverse CT gap conduction was found in three patients during CS pacing and in three patients during LARA pacing. During ULR, CV(L) was greater than CV(T) (1.28 +/- 0.43 vs. 0.73 +/- 0.30 m/s, p < 0.001). The CV(L)/CV(T) ratio was 1.95 +/- 0.77, which was inversely related to the CT gap width (15.7 +/- 6.8 mm) (p < 0.001). The RFA of the CT gap was successful in 18 patients. Four patients had recurrence of arrhythmias during the follow-up of 11 +/- 3 months. CONCLUSIONS: Most of the CT conduction gaps were functional and only appeared during ULR. The width of the CT gap was inversely related to the anisotropic ratio of the CT. The RFA of the CT gap was effective in eliminating ULR.

Aged↗
PubMed2000

A jump in cycle length of orthodromic common atrial flutter during catheter ablation at the isthmus between the inferior vena cava and tricuspid annulus; evidence of dual isthmus conduction directed to dual septal exits.

INTRODUCTION: In orthodromic common atrial flutter (AFL), details of intraseptal propagation of the flutter (FL) wave exiting from the isthmus between the inferior vena cava and tricuspid annulus (IVC-TA isthmus) remain unknown. We hypothesized the existence of dual septal exits of the FL wave from the IVC-TA isthmus to both the anterior, coronary sinus ostium (CSO-TA) isthmus, and the posterior septal (IVC-CSO) isthmus, and that the IVC-TA isthmus might consist of dual muscle bundles directed to both septal isthmuses over the eustachian ridge; therefore, segmental ablation of the IVC-TA isthmus could change intraseptal FL wave propagation. METHODS AND RESULTS: To test the hypothesis, we investigated the influence of segmental ablation of the IVC-TA isthmus on intraseptal FL wave propagation. In seven of 40 (18%) consecutive patients, segmental ablation of the ventricular side of the IVC-TA isthmus during orthodromic common AFL led to sudden prolongation of the flutter cycle length (FCL) (from 266 +/- 33 ms to 291 +/- 45 ms) associated with changes in intraseptal activation sequences. They consisted of prolongation of the interval between the IVC-TA isthmus and the CSO (from 38 +/- 13 ms to 86 +/- 25 ms), shortening of the interval between the CSO and His (from 31 +/- 15 ms to 9 +/- 15 ms), and atrial electrogram polarity change at the His-bundle recording site. Morphological change in the FL wave was also seen on the 12-lead ECG. CONCLUSIONS: In some patients, segmental ablation of the IVC-TA isthmus can lead to a jump in FCL and changes in intraseptal activation sequences of FL waves due to anterior-to-posterior shifting of the septal exit. This indicates that the IVC-TA isthmus may contain dual circumferential muscle bundles as conduction pathways directed to dual septal exits both anterior and posterior to the CSO.

Atrial Flutter↗