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8/7/2019 AF clockwise or anticlockwise
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BY
Dr. Rania samir
Lecturer o Car io ogy
Ain Shams University
Atrial flutter represents the most important &most common atrial tachyarrhythmia after AF
The re-entry circuits often occupy large areas -
reentrant
The overall incidence of atrial flutter in a
recent population study was 0.88%,
0.05% in patients < 50 years old5.87% among individuals > 80 years of age.
(Granada et al, 2000)
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Many different forms of atrial flutter exist & since it
,
used to characterize atrial flutter, particularly
recently, to the point that atrial flutter terminology
has become quite confusing
.
First simple classification based on ECG patterns, in1970
-T ical atrial flutter Counter-clockwise
- Atypical atrial flutter (Clockwise)
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Based on advanced EP mapping techniques which identified different EP-mechanisms of atrial flutter
-atrial flutter
atrial flutter
Atypical atrial flutter
The re-entry circuit isconfined to RA & involvesthe CTI as a critical zone of
slow conduction
any fixedmacroreentrant atrial
circuit that doesntinvolve the CTI
Type II atrial flutter
heterogenous flutterwave morphology
May be due to rapidreentry with
CCW A. flutter
(commonest 90%)
CW A. flutter (less
commom 10%)
Lower loop re-entrry
Lesion macroreentrantatrial tachycardia (mostcommon)
upper loop reentry
LA flutter (rare)
variable fib.
Conduction
ACC/AHA/ESC Guidelines 2003
isthmus dependent atrial
due to a macroreentrant
circuit rotating in either a
counterclockwise
(common) or clockwise
(uncommon) direction inIAS
CT
e r g a r um, w an
area of relatively slowconduction in the low
posterior right atrium
IVCER
CS
TA
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Atrial flutter is most often a nuisance arrhythmia & itsclinical si nificance lies lar el in its fre uentassociation with AF or rapid ventricular responsewhich is principally responsible for many of theassociated symptoms So, maintenance of SR afterCV is mandatory in cases of recurrent A.flutter
,offered a limited ability to maintain SR withoutoccasional to frequent recurrences of A.flutter, evenwhen multiple agents are used.
Reported long term success rates ranging from 50% forclass I to 73% for class III (oral dofetilide)
Also, long-term rate control alone usually requires largedoses of AV nodal blocking agents
Singh et al, Circulation 2000
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Approaches to endocardial mapping of A flutter
include standard multielectrode catheters, Expanding
e ec ro e arrays or mapp ng ec n ques u s
Standard multielectrode catheter-based mapping still
remains the main tool for the study of A flutter
The recent advances in this therapeuticapproac were assoc a e w g success
rates, low recurrence rates and minimalcomplications.
IAS
LAOLAO
IAS
Isthm
IsthmIVC
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Large randomized trials, RF- ablation creating linear lesionsacross the critical zone of slow conduction (CTI) till achievemento as an en po n o a a on
High success rates 90-100%
Low recurrence rate 6-9%
over a period of 9-17 mo
(Tai et al., 1998) (Wu et al.,2002)
RAOLAO
Ain Shams University EP lab
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During PCS pacing
Before ablation After ablation
Complete CW block
Ain Shams University EP lab
LRA pacing
Before ablation After ablation
Complete CCW block
Ain Shams University EP lab
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Variation in the isthmus widthIsthmus width 17-54 mm
Isthmus width > 39 mm or Cath-IVC an le 5mm deep pouch
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Comparing the published success rates of AADs inmaintaining SR to significantly high long term success rates
of RF-ablation Favors RF ablation as an acceptabletherapeutic approach of A . flutter
ACC/AHA/ESC guidelines,2003
Although the success rates of RF-ablationusing conventional & 3D mapping techniquesare similar
Shorter fluoroscopy time (3.915 vs 22 6.3 min)(Kottkamp et al, 2000)
Precise identification of discrete gaps withinnon-contiguous lesion lines the ability to
sites Fast & reliable identification of WSDP along
the ablation line
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TCL 240 ms
Ain Shams University EP lab
CS pacing before ablationCS pacing after ablationshowing CW isthmus block
Ain Shams University EP lab
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Before ablationAfter ablation
Ain Shams University EP lab
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Isthmus ablation in patients with atrial flutter hasproved positive impact on QOL.
a e er a a on s cura ve n many pa en sobviating the need for life-long AADs,and may bemore cost effective on the long term than AADtherapy.
Substantial fluoroscopy exposure, whichis necessaryor conven ona s mus a a on, s s gn can y
reduced with 3D mappingfor isthmus ablation whichhave an impact on the long-term safety of this invasivetreatment strategy.