Typical Atrial Flutter..pdf

Typical Atrial Flutter

Matt Wright

St. Thomas’ Hospital

London

Heart Rhythm Congress

Birmingham, 2011

Typical Right Atrial Cavotricuspid

Dependent Flutter

• A macro re-entrant arrhythmia

– Anatomical barrier

– Zone of slow conduction

• Typical CTI Dependent atrial flutter

– Contained within the right atrium

– Constrained anteriorly by the tricuspid valve

– Constrained posteriorly by the crista terminalis and eustachian ridge

– Travels in a counterclockwise direction around the atrium

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Atrial Flutter

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Atrial Flutter

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Atrial Flutter: Activation Mapping

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Atrial Flutter: Positioning

Catheters

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Atrial Flutter: Anatomy

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Confirmation of Diagnosis

• Careful examination of the surface ECG

• If suspected:

–low to high activation of septum

–high to low activation of the lateral wall

–CS activation proximal to distal, earlier than His A

• Entrainment

–Two disparate sites within the circuit (PPI-TCL

<30ms)

–On the isthmus- concealed entrainment Heart Rhythm Congress

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Atrial Flutter: Lesion

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Endpoint: Bidirectional

Conduction Block

• After RF terminates atrial flutter

conduction through the isthmus often

persists

• Conduction slowing often occurs before

isthmus block

–conduction slowing can be rate dependent

• Recovery of conduction after initial

isthmus block is common Schwartzman et al J Am Coll Cardiol 1996; 28:1519

Shah et al J Am Coll Cardiol 2000; 35: 1478

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Differential Pacing

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Double Potentials

Tada JACC 2001;38:750

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Markers of Conduction Block

• increase in trans-isthmus conduction time differential pacing

• double potentials 100 - 110 ms interval between potentials

• along entire ablation line

differential pacing

• reversal of electrogram polarity on the opposite side of the ablation line from the pacing site

• change in p-wave morphology pacing lateral to the ablation line

Tada JACC 2001;38:750. Tai JICE 2002;7:77. Chen JICE 2002;7:67.

Tada JCE 2001;12:393. Shah JCE 1999;10:662. Circ 1997;96:2505.

Nakagawa Circ 1996;94:3204. Poty Circ 1996;94:3204

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Plateau

Rapid descent

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Differential Pacing: Lateral

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Differential Pacing: Closer to Line

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Differential Pacing: On the line

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61 patients > 1 episode of atrial flutter

no prior antiarrhythmic drug therapy

Antiarrhythmic Drug Therapy sotalol, amiodarone

flecainide, procainamide,

propafenone

RF Ablation > 90% reduction in

electrogram amplitude

along ablation line

Atrial Flutter Recurrence:

Atrial Fibrillation:

Sinus rhythm last f/u

mean follow-up: 22 months

Drug therapy vs first-line ablation for

atrial flutter

Natale et al J Am Coll Cardiol 2000

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Pérez et al. Circulation EP 2009

Results

• Meta-analysis of 10 year period (10719 pts)

• Acute success rate of 91% and 88% (8mm

vs irrigated)

• Recurrence rates 9% with bidirectional block

vs 24%

• Atrial Fibrillation seen 34% patients during

follow up

• Previous AF 53%; new diagnosis 23% Heart Rhythm Congress

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Summary

• Catheter ablation is first line therapy for

typical flutter

• It’s a macro-reentrant tachycardia

• Activation and entrainment maneuvres are

used to confirm the diagnosis

• Long term success rates > 90%

• Bidirectional block not termination of flutter is

the endpoint

• Atrial Fibrillation seen 34% patients during

follow up Heart Rhythm Congress

Birmingham, 2011

Matt Wright MRCP PhD

Cardiac Electrophysiology

Rayne Institute

Department of Cardiology

St. Thomas' Hospital

Westminster Bridge Road

London

SE1 7EH

United Kingdom

email: matthew.wright@kcl.ac.uk

Atrial Flutter

Birmingham, 2011

Atrial Flutter

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Atrial Flutter

Birmingham, 2011

Atrial Flutter: Anatomy

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Atrial Flutter

Birmingham, 2011

Pitfalls Assessing Block

Birmingham, 2011

Typical Atrial Flutter..pdf

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