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PubMed1978

Lidocaine-induced cardiac rate changes in atrial fibrillation and atrial flutter.

To assess atrial and ventricular rate changes after lidocaine injection, 18 atrial flutter patients and 35 atrial fibrillation patients were given intravenous lidocaine, mean dose 100 mg. Continuous electrocardiographic recording for 5 minutes before and at least 10 minutes after lidocaine injection was used to determine rate changes. The atrial flutter rate decreased after lidocaine in 17 of 18 patients (94 per cent), mean maximal decrease 27 beats/minute. The ventricular rate response in atrial flutter was variable but in three patients increased 21, 27, and 47 beats/minute respectively (P less than 0.001). In atrial fibrillation, the mean ventricular rate after rapid lidocaine injection increased six beats/minute (P less than 0.01). In three of 35 atrial fibrillation patients (9 per cent), the ventricular rate increase was greater than 20 beats/minute (P less than 0.001), and in two patients (6 per cent), the ventricular rate increase was associated with potentially serious clinical events. Lidocaine-induced ventricular rate increases are common in atrial flutter and fibrillation, particularly in patients who are also receiving quinidine.

Adult↗
PubMed2003

Impaired longitudinal conduction in crista terminalis is necessary for sustenance of experimental atrial flutter.

Sustained atrial flutter (AFL) can be induced by creating a lesion between the vena cava in dogs. In previous studies on this model, the crista terminalis (CT) was often injured, and thus, role of CT in sustained reentry was not well understood. We hypothesized that impaired longitudinal conduction in CT is necessary for sustained AFL. In 16 anesthetized, open-chest dogs, linear radiofrequency ablation of the intercaval region was performed without interrupting CT. Intra-atrial conduction times (IAT) along CT were measured using a plaque electrode (25x35 mm) containing 30 bipolar electrodes before and after additional ablation of CT (group A, n=10) or the pectinate muscle (PM) region (group B, n=6). In group A, IAT along CT was 27 +/- 5 ms at baseline and was increased to 43 +/- 3 ms after ablation of CT (P<0.001). In group B, IAT along CT was 28 +/- 4 ms at baseline and 27 +/- 3 ms after ablation of PM (P=NS). Sustained AFL lasting >20 minutes was induced in 10/10 dogs in group A only after additional ablation of CT, and in 0/6 dogs in group B (P<0.001). The cycle lengths of AFL after ablation of the intercaval region and additional ablation of CT were 119 +/- 14 and 140 +/- 14 ms, respectively (P<0.01). There was a significant positive correlation between the cycle length of AFL and IAT along CT (r2=0.63, P<0.001). These results indicate that longitudinal conduction property in CT and not in PM strongly affects sustenance of AFL in this model.

Analysis of Variance↗
PubMed2001

Predictors of failure of transoesophageal cardioversion of common atrial flutter.

BACKGROUND: Common atrial flutter is due to a re-entry circuit in the right atrium. It is possible to entrain and interrupt this arrhythmia with transoesophageal pacing (TEAP) in a substantial percentage of patients. The aim of this study is to evaluate factors associated with failure of transoesophageal cardioversion of common atrial flutter. METHODS: One hundred consecutive patients underwent an attempted transoesophageal cardioversion of their common atrial flutter. In order to detect factors associated with failure of this procedure, the following were considered: (a) age and gender; (b) underlying heart disease; (c) time of onset of the arrhythmia; (d) antiarrhythmic treatment at the time of cardioversion; (e) flutter cycle length, (f) A/V deflection ratio at the site of transoesophageal pacing; and (g) longitudinal and transverse diameters of right and left atrium on the echocardiogram. RESULTS: In 84 of 100 patients, TEAP modified the atrial flutter circuit: in 23 of these, sinus rhythm was restored; in 31 patients, flutter was converted into atrial fibrillation which spontaneously reverted to sinus rhythm; and in remaining 30 patients, persistent atrial fibrillation was obtained. In 16 cases, no modification in atrial flutter circuit was obtained by TEAP (Group 2). Using univariate analysis, this group of patients showed no significant difference in flutter cycle length, a smaller A/V ratio at the site of TEAP, a longer transverse diameter of left atrium and a shorter transverse diameter of right atrium. Analysis of the therapy at cardioversion shows that no Group 2 patients was on intravenous amiodarone, while a greater percentage of patients of the former group was on chronic amiodarone treatment. A logistic regression model applied to the data showed that flutter cycle length, transverse diameter of left atrium and A/V deflection ratio at the site of TEAP were independent variables with influence on the failure rate. CONCLUSION: Transoesophageal pacing is able to modify the circuit of common atrial flutter in a large percentage of patients, and can convert this arrhythmia to sinus rhythm in more than 50% of cases. Failure of this procedure is associated with electrophysiological parameters (flutter cycle length, A/V ratio at the site of TEAP), anatomical factors (left and right atrial diameters) and treatment in use at the time of TEAP.

Adult↗
PubMed2005

Atypical access to typical atrial flutter.

Typical atrial flutter with reentry around the tricuspid valve can easily be cured by ablating the cavotricuspid isthmus. In the reported case, transvenous access to the tricuspid valve was not possible because of a total cavopulmonal connection in congenital mitral atresia. Successful angioplasty of a small fenestration between the total cavopulmonal connection and the genuine right atrium (RA) allowed anterograde transvenous access to the RA. Electroanatomic RA mapping confirmed peritricuspid reentry, and successful ablation was performed.

Adolescent↗
PubMed1993

Catheter ablation of atrial flutter circuits.

Atrial flutter (AF) mapping has shown circular activation in the right atrium (RA), with a "counterclockwise" rotation in a frontal view. The myocardial isthmus between the inferior vena cava and the tricuspid valve (IVC-T) closes the activation circuit in its caudal end. The reproducibility of this activation pattern, and the fact that some "rare" AF with a "clockwise" rotation of activation use the same circuit, suggests that reentry is greatly facilitated by the anatomical arrangement of the caudal end of the RA. This suggested that ablation of the IVC-T isthmus may interrupt AF and prevent its recurrence. We have applied radiofrequency (RF) current to the IVC-T isthmus in nine patients, producing sudden interruption of activation at this point in five (all those treated with large surface electrode catheters). In three others, RF produced acceleration or disorganization, leading to interruption. Preliminary follow-up data suggest a favorable effect on AF recurrence, either by preventing it, or by making antiarrhythmic drugs effective.

Atrial Flutter↗
PubMed2005

Severe left ventricular systolic dysfunction increases atrial fibrillation after ablation of atrial flutter.

BACKGROUND: Atrial fibrillation (Afib) that occurs after a successful atrial flutter (AFL) ablation may negate the potential benefits of the ablation. Afib occurs more often when severe left ventricular systolic dysfunction (LVSD) is present. We hypothesized that even after a successful AFL ablation, the incidence of postablation Afib is increased when severe LVSD is present. METHODS: Ninety consecutive patients with LVSD who underwent ablation for AFL at Montefiore Medical Center from August 2001 to January 2005 were classified according to the severity of LVSD. Group 1 (n = 36) consisted of patients with EF < or = 35%, and group 2 (n = 54) consisted of patients with EF 36-55%. There were no statistically significant differences in baseline patient characteristics between the two groups. RESULTS: During a mean follow up of 350 days, Afib occurred in 31% (n = 11; 8 with prior history of AFib) in group 1, and 7.4% (n = 4; all with prior history of Afib) in group 2. Cumulative probability of remaining Afib-free in group 1 versus group 2 was 75% versus 96% at 365 days, and 69% versus 91% at 600 days (P = 0.01). A prior history of Afib did not interact with EF when analyzed with a logistic regression analysis. CONCLUSION: After an AFL ablation, the incidence of Afib is increased, and the probability of remaining free of Afib is decreased, when severe LVSD is present, independent of a prior history of Afib. This finding may have implications for optimal patient selection for AFL ablation, and the use of adjunctive therapies.

Atrial Fibrillation↗
PubMed2002

The arrangement of muscle fibres in the region of the subthebesian fossa in the aspect of atrial flutter.

The typical atrial flutter is the most common supraventricular tachycardia with reentrant circuit. This tachyarrythmia is based on macroreentry wave going around established anatomic landmarks. The reentry in the inferior right atrial wall passes through narrow isthmus, which is the goal for ablative therapy. The isthmus area is bordered anteriorly by the tricuspid valve and posteriorly by the inferior vena cava, coronary sinus, and eustachian ridge. Near to this area we can find anatomical structure, which can be very important during arising, perpetuation and curing of atrial flutter. The concavity, so-called subthebesian fossa, is on the way of typical atrial flutters' reentrant circuit. Regarding the facts mentioned above we decided to examine the morphology and the arrangement of the muscle fibres in this fossa. Research was conducted on material consisting of 70 human hearts of both sexes from the age of 34 to 72 years. 50 hearts came from patients whose death was not cardiologic in origin. 20 hearts came from humans in whose common atrial flutter was confirmed. We observed the arrangement of muscle fibres in the area of subthebesian fossa. Besides we measured the size and deepness of the subthebesian fossa in both groups of hearts. We found that regular arrangement of muscle fibres within subthebesian fossa was present in 23 healthy human hearts (46%) and 7 cases (35%) of hearts with atrial flutter. The irregular arrangement of muscle fibres was observed in 27 hearts (54%) of control group and 13 hearts (65%) with dysrrhythmia. The thickness of the right atrial wall within the subthebesian fossa was very thin in 8 normal hearts (16%) and in 5 dysrrhythmic hearts (25%). The sizes of examined structure were variable in both groups of hearts, and are presented in the table. It seems that the subthebesian concavity can be the substrate for reentrant circuit during atrial flutter, and there could be such special arrangement of muscle fibres, which allows for microreentrant circuit to arise in this area.

Adult↗
PubMed2006

Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter.

BACKGROUND: There is no published randomized study comparing amiodarone therapy and radiofrequency catheter ablation (RFA) after only 1 episode of symptomatic atrial flutter (AFL). The aim of the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) Trial of Atrial Flutter was 2-fold: (1) to prospectively compare first-line RFA (group I) versus cardioversion and amiodarone therapy (group II) after only 1 AFL episode; and (2) to determine the impact of both treatments on the long-term risk of subsequent atrial fibrillation (AF). METHODS AND RESULTS: From October 2002 to February 2006, 104 patients (aged 78+/-5 years; 20 women) with AFL were included, with 52 patients in group I and 52 patients in group II. The cumulative risk of AFL or AF was interpreted with the use of Kaplan-Meier curves and compared by the log-rank test. Clinical presentation, echocardiographic data, and follow-up were as follows: age (78.5+/-5 versus 78+/-5 years), history of AF (27% versus 21.6%); structural heart disease (58% versus 65%), left ventricular ejection fraction (56+/-14% versus 54.5+/-14%), left atrial size (43+/-7 versus 43+/-6 mm), mean follow-up (13+/-6 versus 13+/-6 months; P=NS), recurrence of AFL (3.8% versus 29.5%; P<0.0001), and occurrence of significant AF beyond 10 minutes (25% versus 18%; P=0.3). Five complications (10%) were noted in group II (sick sinus syndrome in 2, hyperthyroidism in 1, and hypothyroidism in 2) and none in group I (0%) (P=0.03). CONCLUSIONS: RFA should be considered a first-line therapy even after the first episode of symptomatic AFL. There is a better long-term success rate, the same risk of subsequent AF, and fewer secondary effects.

Aged↗
PubMed1989

Efficacy and safety of intravenous diltiazem for treatment of atrial fibrillation and atrial flutter. The Diltiazem-Atrial Fibrillation/Flutter Study Group.

This study evaluates the effectiveness and safety of intravenous diltiazem for the treatment of atrial fibrillation and atrial flutter. A double-blind, parallel, randomized, placebo-controlled protocol was used, and 6 large, urban hospitals, both university-affiliated and private, participated. The study involved 113 patients with atrial fibrillation or flutter, a ventricular rate greater than or equal to 120 beats/min and systolic blood pressure greater than or equal to 90 mm Hg without severe heart failure. The dose of intravenous diltiazem (or identical placebo) was 0.25 mg/kg/2 minutes followed 15 minutes later by 0.35 mg/kg/2 minutes if the first dose was tolerated but ineffective. If a patient did not respond, the code was broken and the patient was allowed to receive open-label diltiazem if placebo had been given. Of 56 patients, 42 (75%) randomized to receive diltiazem responded to 0.25 mg/kg and 10 of 14 responded to 0.35 mg/kg, for a total response rate of 52 of 56 patients (93%), whereas 7 of 57 patients (12%) responded to placebo (p less than 0.001). After the double-blind protocol, 49 of the 57 patients who received placebo were then given diltiazem; 47 of 49 responded, for an overall response rate of 99 of 105 patients (94%) with diltiazem. The median time from the start of drug infusion to the maximal decrease in heart rate was 4.3 minutes. Side effects occurred in 14 patients, 7 of whom had asymptomatic hypotension not requiring intervention. Thus, intravenous diltiazem was rapidly effective for slowing the ventricular response in most patients with atrial fibrillation or atrial flutter. Blood pressure decreased slightly. Side effects were mild.

Aged↗
PubMed1984

Atrial flutter treatment by rapid atrial pacing.

49 patients with 53 episodes of atrial flutter were treated by rapid atrial pacing. Sinus rhythm was attained in 55%, atrial fibrillation in 26%, type II flutter in 9% of patients. In the other cases, the effect on atrial action was only slight or short-lasting. Among the causes of the unsuccessful outcome of treatment, the authors include--besides insufficient rate and duration of pacing, bad electrode contact in the atrium and insufficient outlet current--specific properties of the type of flutter (impure flutter, type II flutter, type I atrial fibrillation, uncommon flutter) as well as unsuitable indication (mitral defect, thyrotoxicosis).

Atrial Fibrillation↗
PubMed2000

Importance of atrial flutter isthmus in postoperative intra-atrial reentrant tachycardia.

BACKGROUND: In survivors of congenital heart surgery, intra-atrial reentrant tachycardia (IART) often develops. Previous reports have emphasized the atriotomy scar as the central barrier around which a reentrant circuit may rotate but have not systematically evaluated the atrial flutter isthmus in such patients. We sought to determine the role of the atrial flutter isthmus in supporting IART in a group of postoperative patients with congenital heart disease. METHODS AND RESULTS: Nineteen postoperative patients with IART underwent electrophysiological studies with entrainment mapping of the atrial flutter isthmus for determining postpacing intervals. Radiofrequency ablation was performed at the identified isthmus in an effort to create a complete line of block. Twenty-one IARTs were identified in 19 patients, with a mean tachycardia cycle length of 293+/-73 ms. The atrial flutter isthmus was part of the circuit in 15 of 21 (71. 4%). In the remaining 6 of 21, the ablation target zone was at sites near atrial incisions or suture lines. Ablation was successful in 19 of 21 (90.4%) IARTs and in 14 of 15 (93.3%) cases at the atrial flutter isthmus. CONCLUSIONS: In most of our postoperative patients, the atrial flutter isthmus was part of the reentrant circuit. The fact that the atrial flutter isthmus is vulnerable to ablation suggests that whenever IART occurs late after repair of a congenital heart defect, the atrial flutter isthmus should be evaluated. These data support the theory that some form of conduction block between the vena cava is essential for the establishment of a stable substrate for the atrial flutter reentrant circuit.

Adolescent↗
PubMed1987

Termination of spontaneous atrial flutter by transesophageal pacing.

Transesophageal atrial pacing using the constant-rate technique was performed in 26 patients presenting with spontaneous atrial flutter (atrial cycle length between 180 and 270 ms). All but one patient had been treated with one or more antiarrhythmic agents (digoxin, quinidine, procainamide, propranolol, verapamil, diltiazem, and propafenone) within the previous 12 hours. Transesophageal atrial pacing at cycle lengths between 80 and 180 ms was successful in terminating atrial flutter in 22 patients: immediate reversion to sinus rhythm in 16, following transient sinus pause in one, following a brief period of atrial fibrillation in three, and following longer periods of atrial fibrillation in another two. No post-conversion ventricular arrhythmia and no other complications were observed. All patients experienced only a mild burning discomfort during the procedure. It is concluded that atrial pacing via the esophagus is a safe and noninvasive technique of terminating spontaneous atrial flutter. The effectiveness of this technique is comparable to endocardial or epicardial atrial pacing.

Adolescent↗
PubMedDate not supplied

[Trans-surgical ablation of atrial flutter in patients treated with closure of atrial septal defect. Pilot project].

Atrial flutter is one of the most common arrhythmias in patients with atrial septal defect, after surgery 14% of patients can develop it and may be associated with high morbidity. In this study we performed prophylactic and therapeutic ablation of atrial flutter during atrial septal closure surgery drawing 4 lines; line 1, isthmus cavo-tricuspid, the area between the inferior vena cava and the tricuspid ring; line 2, the area between coronary sinus ostium and inferior vena cava; line 3, the area between tricuspid valve annulus and coronary sinus ostium; and line 4, the area between lateral atriotomy and atrial septal defect. Twenty-one patients were included, 6 (28.5%) patients had atrial flutter before surgery and 15 (71.4%) were in sinus rhythm. There were no new cases of atrial flutter, but at six months follow up 2 (33.3%) patients recidivated with atrial flutter. One patient developed high degree atrio-ventricular block and a pacemaker had to be implanted. Older age at the time of surgery and high systolic pulmonary pressure were significantly higher in those patients with atrial flutter before surgery and in patients with arrhythmias recurrence. Ablation of atrial flutter during atrial septal closure surgery can be a good option for the treatment and prevention of atrial arrhythmias, but more studies are still needed.

Adolescent↗
PubMed1994

Patterns of interruption of atrial flutter induced by rapid atrial pacing.

We evaluated the patterns of interruption of atrial flutter (AFl) induced by rapid atrial pacing in 10 patients using standard electrophysiologic techniques. We observed 3 patterns of interruption of AFl: 1) interruption resulting from block of an orthodromic wavefront within the reentry loop in 5 patients; 2) interruption when pacing impulses no longer captured all of the recording sites in the atrium during rapid atrial pacing in 2 patients, and 3) interruption with 1 echo wave after the cessation of pacing in 3 patients. These findings suggest that there are patterns of interruption of AFl other than that resulting from a simple block of an orthodromic wavefront within the reentry loop.

Aged↗
PubMed2000

Basket catheter localization of the origin of atrial tachycardia with atypical morphology after atrial flutter ablation.

Atrial activation from a site in the low lateral right atrium will typically proceed in a superior direction. We present a case of a low lateral right atrial tachycardia with a surface electrocardiographic P wave morphology that appeared to have an inferiorly directed axis. The tachycardia occurred 2 years after successful atrial flutter ablation. The use of a multipolar basket catheter allowed confirmation of the focal origin of the tachycardia, permitted its rapid localization, facilitated catheter ablation, and provided clues to atrial activation that helped describe the appearance of the P wave.

Cardiac Catheterization↗
PubMed1999

Effect of right atrial isthmus ablation on the occurrence of atrial fibrillation: observations in four patient groups having type I atrial flutter with or without associated atrial fibrillation.

BACKGROUND: The goal of this study was to test the hypothesis that the occurrence of atrial fibrillation (AF), in at least some patients with coexisting type I atrial flutter (AFL), is based on macro-reentry around the tricuspid valve orifice, including the right atrial (RA) isthmus, by evaluation of AF recurrences after successful ablation of AFL. METHODS AND RESULTS: Eighty-two consecutive patients with type I AFL, with or without concomitant AF, underwent radiofrequency ablation (RFA) of the RA isthmus by an anatomical approach. The results were analyzed in 4 groups of patients: group 1 (only AFL; 29 patients), group 2 (AFL >AF; 22 patients), group 3 (AF >AFL; 15 patients), and group 4 (developing AFL while receiving class IC antiarrhythmic drug therapy for AF, the "class IC atrial flutter"; 16 patients). In all groups, RFA of type I AFL was performed with a high (>/=93%) procedural success rate. In group 1, only 2 patients (8%) had AF after (18+/-14 months) AFL ablation. These figures were 38% (20+/-14 months) and 86% (13+/-8 months) in groups 2 and 3, respectively. Group 4 patients (4+/-2 months) had a 73% freedom of AF recurrences with continuation of the class IC agent. CONCLUSIONS: The low incidence of new AF during long-term follow-up after RFA of type I AFL makes it unlikely that radiofrequency lesions promote the development of AF. The impact of isthmus ablation on AF recurrences differs according to the clinically predominant atrial arrhythmia and suggests a possible role of the RA isthmus in the occurrence of AF in some patients. Ablation of class IC atrial flutter in patients with therapy-resistant AF is a novel approach to management of this patient subset. Careful classification of AF patients plays a role in the selection of the site of ablation therapy.

Aged↗