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PubMed2000

Automated discrimination between atrial fibrillation and atrial flutter in the resting 12-lead electrocardiogram.

Computerized time-domain analysis of the QRST-subtracted 12-lead electrocardiogram (ECG) has been used successfully to determine several atrial activity patterns. These time-domain methods are particularly useful for low-frequency signals such as those originating at the sinus node. However, high frequency atrial fibrillation (AFIB) and atrial flutter (AFL) waves can be better estimated by using spectral methods. In this study, we investigated the use of spectral entropy (SE) and spectral peak detection to distinguish fibrillatory from flutter activity in the QRST-subtracted ECG. In a set of 4,172 cardiologist-overread ECGs, a computerized ECG analysis program (12SL MAC-Rhythm, GE-Marquette Medical Systems, Milwaukee, WI) detected 270 AFIB rhythms and 100 AFL rhythms. Compared to the cardiologist's reading, the AFIB versus AFL miss-classification error was 5.6%. The Fourier Transform was used to estimate the power spectral density of the QRST-subtracted ECG data. Individual lead spectra were then averaged and SE was computed for each of the ECGs originally called AFIB or AFL by the computer program. Additional criteria that included SE, spectral peak frequencies, and time-domain measures of atrial activity were then applied to discriminate between the 2 rhythms. Employing these criteria resulted in a decrease of miss-classification error to 2.5%.

Algorithms↗
PubMed1993

Right ventricular cardiomyopathy similar to Uhl's anomaly with atrial flutter and complete AV block.

We report an adult patient with right ventricular cardiomyopathy similar to Uhl's anomaly. In this patient an interesting manifestation is a transient atrial flutter with complete A-V block. Right ventricular cardiomyopathy (arrhythmogenic right ventricular dysplasia) is considered a cause of life-threatening arrhythmia. The right ventricular musculature is partially or totally absent and is replaced by fatty and fibrous tissue. Patients may present with ventricular arrhythmias, right heart failure or asymptomatic cardiomegaly. Only a few cases with atrioventricular conduction disturbance have been reported in the literature by now. We report such a case.

Animals↗
PubMed1984

Conversion of longstanding atrial flutter to sinus rhythm and transient complete A-V block following oral administration of verapamil. Report of a case.

In a patient with ischaemic heart disease chronic atrial flutter reverted to sinus rhythm during treatment with oral Verapamil, given at dosage of 240 mg once a day in order to prevent spontaneous angina. Such an unexpected event was accompanied by a remarkable sinus node depression and by a transient complete a-v block, that gradually subsides leaving a slight permanent a-v conduction delay. Either a higher bioavailability of the drug or an extremely increased sensitivity of the receptors can explain such a marked electrophysiological effect at a moderate drug dosage.

Aged↗
PubMed2003

Surface electrocardiographic characteristics of right and left atrial flutter.

BACKGROUND: There is little information about the surface expression of non-cavotricuspid isthmus (CTI)-dependent right atrial (RA) or left atrial (LA) flutter circuits. METHODS AND RESULTS: We retrospectively evaluated 32 episodes (in 26 patients) of atypical RA and 22 episodes (in 21 patients) of LA flutter. The surface ECG of 13 patients with lower-loop reentry was similar to that of their pattern during counterclockwise (CCW) CTI atrial flutter (AFL), except for decreased amplitude of the terminal forces in the inferior leads. In 11 of 24 episodes characterized by high or multiple breaks over the crista, the ECG showed changes that depended on the initial activation sequence of the LA. In 7 of 8 episodes of upper-loop reentry, the ECG pattern completely mimicked that for clockwise (CW) CTI AFL. All 11 patients with an LA septal circuit showed a typical ECG pattern characterized by prominent forces in lead V1 with flat deflections in the other surface leads. Eleven patients with other LA circuits had a more variable pattern but showed decreased voltage in the inferior leads compared with that of a group with CCW-CTI AFL (1.6+/-1 vs 2.68+/-0.7 mV, respectively; P<0.05). CONCLUSIONS: The RA surface-ECG patterns different from those of CCW or CW-CTI could still be CTI dependent. In contrast, a typical CW-CTI surface pattern was always seen in patients with upper-loop reentry, which was non-CTI dependent. LA AFL circuits had either flat or low-amplitude forces in the inferior leads.

Aged↗
PubMed2004

Safety and efficacy of intravenously administered tedisamil for rapid conversion of recent-onset atrial fibrillation or atrial flutter.

OBJECTIVES: The goal of the present study was to assess the efficacy and safety of intravenous tedisamil, a new antiarrhythmic compound, for conversion of recent-onset atrial fibrillation (AF) or atrial flutter (AFL) to normal sinus rhythm (NSR). BACKGROUND: Tedisamil is a novel antiarrhythmic drug with predominantly class III activity. Its efficacy and safety for conversion of recent onset AF or AFL to NSR is not known. METHODS: This was a multicenter, double-blind, randomized, placebo-controlled, sequential ascending dose-group trial. A total of 201 patients with symptomatic AF or AFL of 3 to 48 h duration were enrolled in a two-stage study. During stage 1, patients were randomized to receive tedisamil at 0.4 mg/kg body weight or matching placebo; during stage 2, patients received tedisamil at 0.6 mg/kg body weight or matching placebo. Treatments were given as single intravenous infusions. The primary study end point consisted of the percentage of patients converting to NSR for at least 60 s within 2.5 h. RESULTS: Of 175 patients representing the intention-to-treat sample, conversion to NSR was observed in 41% (25/61) of the tedisamil 0.4 mg/kg group, 51% (27 of 53) of the tedisamil 0.6 mg/kg group, and 7% (4/59) of the placebo group (p < 0.001 for both tedisamil groups vs. placebo). Average time to conversion was 35 min in patients receiving tedisamil. There were two instances of self-terminating ventricular tachycardia: one episode of torsade de pointes and one of monomorphic ventricular tachycardia, both in patients receiving 0.6 mg/kg tedisamil. CONCLUSIONS: Tedisamil at dosages of 0.4 and 0.6 mg/kg was superior to placebo in converting AF or AFL. Tedisamil has a rapid onset of action leading to conversion within 30 to 40 min in the majority of responders.

Aged↗
PubMed1999

Role of bipolar electrogram polarity mapping in localizing recurrent conduction in the isthmus early and late after ablation of atrial flutter.

OBJECTIVES: Bipolar electrogram polarity was analyzed to localize the recurrent conduction site in the isthmus between the tricuspid annulus (TA) and inferior vena cava (IVC) in recurrent atrial flutter (AF). BACKGROUND: Despite the initial successful linear isthmus ablation, recurrence of transisthmus conduction and AF is not uncommon. It is unclear how the recurrent conduction site can be identified. METHODS: Fourteen patients with recurrent AF were studied: four with late recurrence remote from the first ablation and 10 with early recurrence within 60 minutes after the initial successful ablation. Bipolar electrogram polarity mapping was performed during low lateral right atrium (LLRA) pacing during sinus rhythm while recording bipolar electrograms from the septal portion of the isthmus along the previously ablated line. The septal side of the isthmus from TA to IVC was arbitrarily divided into five sites, and the bipolar electrodes with cathode at the tip and anode at the second was placed at each site. The recurrent conduction site was localized by analyzing the polarity of the bipolar electrogram recorded at each site. RESULTS: All recurrent AF was due to reentry around TA. During pacing from LLRA, as the mapping electrode was moved from TA to IVC side, the major polarity of the electrogram changed from negative to positive in all patients. A transitional electrogram with the equal amplitudes in positive and negative components was recorded between the sites showing mainly negative and positive electrograms, indicating electrogram polarity reversal at this site. Application of radiofrequency energy to this single site resulted in the elimination of transisthmus conduction in all patients with a single application in 11 patients and 2 or 3 in the remaining 3. CONCLUSIONS: Bipolar electrogram polarity mapping with attention to the polarity reversal point is useful for identifying and ablating the recurrent conduction site.

Adult↗
PubMed2005

[Immediate cardioversion of atrial fibrillation and atrial flutter lasting less than 90 days by ibutilide versus propafenone: a multicenter study].

OBJECTIVE: To compare the efficacy and safety of ibutilide versus propafenone in immediate cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) lasted less than 90 days. METHODS: 212 consecutive patients suffering from AF or AFL all lasting less than 90 days that were diagnosed and treated in 5 medical centers were randomly assigned into two groups: ibutilide group (n = 107, including 75 AF cases and 32 AFL cases, receiving intravenous injection of ibutilide 1mg over 10 minutes) and propafenone group as control group (n = 105, including 76 AF cases and 29 AFL cases, receiving intravenous injection of propafenone 70 mg over 10 minutes). If AF/AFL still persisted 10 minutes after treatment, the above dose was repeated. The conversion rate within 1.5 hours and adverse effects within 4 hours were observed. RESULTS: (1) The conversion rate on AFL of the ibutilide group was 78.1%, significantly higher than that of the propafenone group (48.3%, P < 0.01), while no significant difference was observed in the conversion rate on AF (54.7% vs. 39.5%, P > 0.05) and the mean conversion time (P > 0.05). However the overall conversion rate on AFL and AF of the ibutilide group was 61.7%, significantly higher than that of the propafenone group (41.9%, P < 0.05). (2) The conversion rate on AF/AFL lasting less than 48 h was 65.9% in the ibutilide group, not significantly different from that of the propafenone group (55.7%), the conversion rate on AF/AFL lasting 3 approximately 30 d in the ibutilide group was 66.7%, significantly higher than that of the propafenone group (26.3%, P < 0.05), and the conversion rate on AF/AFL lasting 31 - 88 d was 50%, significantly higher than that of the propafenone group (0, P < 0.01). (3) There was no difference in the times needed for conversion between these 2 groups. (4) The most severe adverse effect in the ibutilide group was short run of ventricular tachycardia occurring in 5 cases among which 4 cases recovered simultaneously and one case recovered after accepting a bolus dose of 100 mg lidocaine. The most severe adverse effects in propafenone group were RR interval longer than 1.5 s (4 cases) and transient hypotension. An acute coronary event was also seen in propafenone group, however, unrelated to the experimental drug. CONCLUSION: Intravenous administration of ibutilide in cardioversion of AF and AFL is safe and effective.

Adolescent↗
PubMedDate not supplied

Intravenous propafenone for suppression of symptomatic atrial fibrillation and atrial flutter in a first aid hospital.

The efficacy and safety of propafenone (PPF) were prospectively evaluated in 20 patients (13 men and 7 women, age 39 +/- 14 years) with atrial arrhythmias (AA) (atrial fibrillation: n = 13; atrial flutter: n = 7). All patients had arrhythmias from 109 +/- 63 minutes, (iT) without clinical evidence of heart failure. Intravenous PPF was given as a 1 mg/kg bolus over 5 minutes, with a therapeutical possibility of a second bolus (1 mg/kg) after 10 minutes if sinus rhythm was not restored. The conversion time (cT) was 6.4 +/- 2.2 minutes (range 3 to 18 minutes). In 19 patients (95%) sinus rhythm was restored and no serious adverse and proarrhythmic effects were noted in each patient. We conclude that 1) PPF is effective and acted significantly faster in controlling AA; 2) PPF appears to be well tolerated and relative safe with a low incidence of adverse and proarrhythmic effects in patients in a first aid station.

Adult↗
PubMed2003

Safety and feasibility of a clinical pathway for the outpatient initiation of antiarrhythmic medications in patients with atrial fibrillation or atrial flutter.

We sought to establish the safety and feasibility of a clinical pathway for the outpatient initiation of antiarrhythmic medications (AAMs) for the maintenance of sinus rhythm in patients with atrial fibrillation (AF) or atrial flutter (AFl). AAMs are frequently utilized to maintain sinus rhythm in patients with AF or AFl. Although they are often initiated in an outpatient setting, there is little prospective evidence for the safety of this approach. Patients with a history of AF or AFl were prospectively monitored with an event recorder during 409 AAM initiation trials. All AAMs were initiated in sinus rhythm. Patients transmitted a recording (30 seconds) once daily for 10 consecutive days. Amiodarone was used for 212 patients (51.8%), 127 (31.1%) received a type 1C AAM, 37 (9.0%) received sotalol, and 33 (8.1%) received a type 1A AAM. Adverse events occurred in 17 patients (3 died, 3 had bradycardia that required permanent pacemaker implantation, and 11 had bradycardia requiring a decrease in the dose of antiarrhythmic or rate-controlling medication). Most events were due to bradycardia in patients who received amiodarone. There was a significant association between amiodarone-associated bradycardia and women. The only event that occurred during the first 48 hours was an episode of bradycardia in a patient who received amiodarone and was managed as an outpatient. The outpatient initiation of AAMs for patients with a history of AF or AFl while in sinus rhythm is associated with significant risk. Most adverse events occurred beyond the usual time period for in-hospital monitoring of the initiation of AAMs.

Adult↗
PubMed1991

Effects of pentisomide and E-4031 on canine atrial flutter due to reentry: a comparative study with disopyramide and propafenone.

Effects of new antiarrhythmic drugs, pentisomide [3.5 +/- 0.5 mg/kg intravenously (i.v.) n = 8], and E-4031 (5.6 +/- 1.0 micrograms/kg, n = 8), a class III drug, on atrial flutter (AF) caused by reentry were compared with those of disopyramide (1.6 +/- 0.2 mg/kg, n = 8) and propafenone (2.2 +/- 0.2 mg/kg, n = 8). AF was induced with burst atrial pacing after we made an intercaval crush in anesthetized, open-chest dogs. Termination of AF did not differ among test drugs (8 of 8 with disopyramide, 7 of 8 with propafenone, 6 of 8 with pentisomide, and 8 of 8 with E-4031). Cycle length (CL) of AF was prolonged more with propafenone (57 +/- 10%) and pentisomide (41 +/- 5%) than with E-4031 (12 +/- 3%, p less than 0.05). This was also true for increase in interatrial conduction time determined at a pacing CL of 150 ms. Increase in atrial effective refractory period (ERP) determined at a basic pacing CL of 300 ms did not differ among test drugs. Changes in CL of AF correlated significantly with those in interatrial conduction time (r = 0.84, p less than 0.001), but not with those of ERP (r = 0.10, NS). Reinitiation of AF was significantly greater in propafenone (7 of 7) and pentisomide (5 of 6) groups than in disopyramide (1 of 8) and E-4031 (0 of 8) groups (p less than 0.001). Pentisomide and E-4031 were effective in terminating canine AF due to reentry, as were disopyramide and propafenone. Reinitiation of AF was greater in dogs treated with antiarrhythmic drugs that had more prominent effects on conduction time than on ERP.

Animals↗
PubMed2003

Use of different catheter ablation technologies for treatment of typical atrial flutter: acute results and long-term follow-up.

OBJECTIVES: We report the acute success and long-term follow-up in consecutive patients undergoing catheter ablation of typical right atrial flutter (AFL) using different ablation technologies. METHODS: One hundred and two patients presenting for treatment of AFL to our laboratory were included in the study. Based on availability and physician preference, ablation was performed with either a cooled-tip catheter (39 patients, group I), an 8- or 10-mm tip catheter connected to a high-power radiofrequency (RF) generator (25 patients, group II), or a 4- or 5-mm tip catheter (38 patients, group III). Acute ablation success was achieved in all group II and group III patients. Among the 38 patients undergoing ablation with the conventional catheter tip (group I), crossover to an 8-mm tip or a cooled tip ablation catheter was required in 11 patients (29%). The mean fluoroscopy time was significantly higher in group I (54.3 +/- 26.4 minutes) when compared to group II (39.6 +/- 19.6 minutes; P < 0.05) and group III (40 +/- 16 minutes; P = 0.0.5). After a mean follow up of 20 +/- 5 months no patient in group II experienced recurrence of AFL, whereas 18.4% (7 of 38 patients; P < 0.05) in group I and 10% (4 of 39 patients; P < 0.05) in group III had recurrence of AFL. Ablation technologies designed to obtain larger size lesions appeared to be more effective in achieving acute ablation success of AFL and in limiting the long-term recurrence rate of this arrhythmia.

Atrial Flutter↗
PubMed2000

Atrial flutter in grown-up congenital heart (GUCH) patients. Clinical characteristics of affected population.

OBJECTIVE: To define occurrence, lesions and clinical characteristics of grown-up congenital heart (GUCH) patients who develop atrial flutter (AFL). DESIGN: All GUCH patients who presented as inpatients or outpatients with documented sustained AFL between 1996 and 1998 were studied prospectively. Retrospective review of case notes for basic data relating to underlying anomaly, prior surgery and age at onset of AFL, enquiry into events before the first attack. Clinical state was assessed by Ability Index before AFL and at last visit. SETTING: Designated quaternary service for GUC in a tertiary referral centre. RESULTS: From October 1996 to April 1998, 100 consecutive patients (49 female) aged 17-77 (mean 35) years, who presented to the GUCH Unit at Royal Brompton Hospital with a sustained attack of AEL documented by a 12 lead electrocardiogram were studied. Four basic cardiac anomalies accounted for 75% patients: one ventricle (26), atrial septal defect (ASD) (19), transposition of great arteries (TGA) (17) and Tetralogy of Fallot (13). AFL occurred occasionally in small ventricular septal defect (VSD), congenital corrected TGA (CC-TGA), pulmonary stenosis and pulmonary atresia with or without VSD. 86/100 patients had undergone cardiac surgery: Fontan 19 (22%), reconstruction of right ventricular outflow tract 17 (20%), closure of ASD 15 (17%), Mustard for TGA 13 (15%), and other palliative surgery 22 (26%). AFL occurred in 'natural history' (unoperated) in 14 (14%) mostly in CC-TGA, ASD and Fallot. Age at first attack was 6-64 (mean 28) years with the first attack occurring at younger age after Mustard (22+/-7 years) and Fontan (24+/-7), than in un-operated ASD (46+/-13) and CCTGA (31+/-10). Haemodynamic abnormalities from anatomical causes were present in 62/74 (84%) patients who had undergone reparative surgery and included venous pathway obstruction, pulmonary regurgitation and pulmonary hypertension. Additional factors which could have precipitated AFL in prone patients were present in 63. New symptoms appeared in 96 patients with the first attack of AFL. Ability Index prior to onset in 90 patients who have been followed-up for more than 1 year since the first onset was 1 in 52, 2 in 31, 3 in 6 and 4 in 1 patients. At the last visit (mean time from the first onset 6.6+/-4.7 years), only 9 patients remained with Ability Index 1, 43 in 2, 20 in 3 and 18 in 4 despite return to sinus rhythm. CONCLUSION: One ventricle heart, ASD, transposition of great arteries and Tetrology of Fallot are the most common underlying anomalies in GUCH patients who develop AFL. It is less commonly seen in unoperated patients. When occurs AFL compromises patients' activities and deteriorates the clinical condition. Residual or developed haemodynamic abnormalities and precipitating factor are often present in this patients, hence full investigation and close follow up are necessary once AFL develops.

Adolescent↗
PubMed2000

Basket catheter-guided three-dimensional activation patterns construction and ablation of common type atrial flutter.

Construction of three-dimensional activation maps and evaluation of ablation-created bidirectional block in the tricuspid valve-inferior vena caval (TV-IVC) isthmus in patients with atrial flutter (AF) are difficult with conventional mapping technique. In 36 patients with type I AF (25 men, 11 women; mean age 62 +/- 10.5 years) a multielectrode basket catheter (BC) was deployed in the right atrium (RA). Out of 64 BC electrodes, 56 bipolar electrograms were derived. Three-dimensional activation patterns were constructed with a software program. Stable electrograms of satisfactory quality were obtained in 49 +/- 2 electrode pairs. Capture was possible in 36 +/- 3 of bipoles. In counterclockwise AF (CCW-AF) and clockwise AF (CW-AF) episodes, cycle lengths and TV-IVC isthmus conduction times were 248 +/- 26 ms and 251 +/- 23 ms, (P = 0.74) and 105 +/- 28 ms and 106 +/- 33 ms (P = 0.92), respectively. Conduction velocity in the TV-IVC isthmus was lower than in the anterior or septal limbs of the circuit, in counterclockwise or clockwise episodes. Double potentials were recorded in 94% of patients. Three-dimensional activation patterns were delineated and displayed as isochronal maps. The reentry circuit involved the TV-IVC isthmus, septal, and anterior walls and a part of the RA roof anterior to superior vena cava. Postablation isthmus conduction was evaluated through the sequence criteria, local electrogram-based criteria, and the analysis of three-dimensional activation patterns of the paced rhythms. The complete isthmus block was associated with a significant increase of the low anterior low septal conduction interval (152 +/- 29 vs 104 +/- 32 ms, P = 0.001) and the low septal-low anterior conduction interval (150 +/- 31 vs 107 +/- 33 ms, P = 0.001). Radiofrequency ablation was successful in 32 (90%) of 36 patients. In conclusion, the current mapping system enables construction of three-dimensional activation patterns and facilitates evaluation of the postablation TV-IVC isthmus block in patients with AF.

Adult↗
PubMed2001

A re-analysis of our current understanding of isthmus-dependent atrial flutter: some gaps, some hypotheses.

The macro-reentrant circuit of isthmus-dependent atrial flutter (AFL) is located in the right atrium around the tricuspid annulus. High acute success and low recurrence rate makes isthmus ablation a definitive therapy for patients with only AFL. However, a review of the literature suggests that, different aspects of this macro-reentrant circuit are still not entirely understood, while new information continues to emerge. The aim of this article is to discuss some gaps in our "complete" understanding of isthmus-dependent AFL. Few hypotheses have been stated which are open to investigation.

Journal Article↗
PubMed1980

Atrial flutter associated with obstructive sleep apnea syndrome. A case report.

An obese 57-year-old man with the obstructive sleep apnea syndrome had partial tracheostomy occlusion and palpitations. Continuous ECG monitoring demonstrated atrial flutter, occasional premature ventricular beats, and a high degree of atrioventricular block during apneic episodes. A 7-s period of ventricular asystole was demonstrated during one such episode. Revision of the tracheostomy produced an improvement in the patient's condition.

Airway Obstruction↗
PubMed1999

A new algorithm to determine complete isthmus conduction block after radiofrequency catheter ablation for typical atrial flutter.

The induction of a complete conduction block of the isthmus between inferior vena cava and tricuspid annulus is considered the best predictor for lack of arrhythmia recurrence if radiofrequency catheter ablation for typical atrial flutter is performed. We evaluated a simplified algorithm to determine complete isthmus block that, in our series, had a predictive accuracy of 100% when compared with the gold standard.

Algorithms↗
PubMed1984

Tracking of atrial flutter during DDD pacing: another form of pacemaker-mediated tachycardia.

Two patients who had DDD pacemakers inserted for symptomatic sick sinus syndrome developed sustained upper-rate limit pacing. It was demonstrated in these two patients that pacemaker-mediated tachycardia was due to tracking of atrial flutter. DDD pacemakers should be used with caution in patients with the sick sinus syndrome and associated atrial tachyarrhythmias. Medical treatment of recurrent atrial tachyarrhythmias may allow patients to remain in the DDD mode.

Aged↗
PubMed1989

Focal right atrial dysplasia and atrial flutter in a patient with myotonic dystrophy.

Focal dysplasia of the right atrium was identified postmortem in a 22-year-old man with myotonic dystrophy and sudden death. Antemortem cardiac abnormalities included a single syncopal episode associated with atrial flutter with exercise-induced 1:1 atrioventricular conduction, sinus node dysfunction, and mild mitral valve prolapse. Pathologically there was only mild conduction system disease and the ventricular myocardium was normal. Right atrial dysplasia, previously unreported in myotonic dystrophy, appears to have been an arrhythmogenic lesion in this patient, serving as a morphological substrate for reentry.

Adult↗