© 2002 by European Society of Cardiology
REGULAR ARTICLES
Atypical atrial flutter: clinical features, electrophysiological characteristics and response to radiofrequency catheter ablation
1Centro Cardiologico Monzino, Institute of Cardiology, University of Milano Italy; 2Cardiology Unit, Azienda Sanitaria Locale, Civitanova Marche Italy
AIMS: To evaluate the clinical and electrophysiological features of atypical atrial flutter (AAF) and its response to radiofrequency catheter ablation.
METHODS AND RESULTS: In 90 consecutive patients referred for sustained atrial flutter, bipolar recordings were obtained from the tricuspid annulus, coronary sinus, interatrial septum and left atrium. AAF was defined by the absence of concealed entrainment from the inferior vena cava — tricuspid annulus isthmus. Target sites were identified by early, fragmented or double potentials and by concealed entrainment. Linear lesions were created between target sites and nearby anatomical barriers in a temperature-controlled mode: 20 episodes of AAFs were documented in 19/90 (21%) patients. Mitral valve disease and surgery were significantly more frequent in patients with AAF. Target sites were identified in the right atrial free wall (n=8), interatrial septum (n=6), left atrium (n=4) and coronary sinus (n=2). Effective ablation was obtained in 15/19 patients (79%). After a 15·7±10·7 month follow-up, AAF recurred in 0/15 patients with a successful and 3/4 (75%) with a failed procedure (P< 0·05).
CONCLUSIONS: Conventional mapping techniques enable identification of critical sites of AAF and allow successful ablation in the majority of cases. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.
Key Words: Atypical atrial flutter, electrophysiological study, intracardiac mapping, radiofrequency ablation
Address for correspondence: Paolo Della Bella, MD, Centro Cardiologico Monzino, Institute of Cardiology, University of Milano, Via C. Parea, 4, 20138 Milano, Italy. Tel.: ++39-02-58002568; Fax: ++39-02-504667; E-mail: pdellabella{at}cardiologicomonzino.it
[1] Feld GK, Fleck P, Chen PS, et al. Radiofrequency catheter for the treatment of human type I atrial flutter. Circulation 1992; 86: 1233–1240.
[2] Anselme F, Saoudi N, Poty H, Douillet R, Cribier A. Radiofrequency catheter ablation of common atrial flutter. Significance of palpitations and quality-of-life evaluation in patients with proven isthmus block. Circulation 1999; 99: 534–540.
[3] Chen SA, Chiang CE, Wu TJ, et al. Radiofrequency ablation of common atrial flutter: comparison of electrophysiologically guided focal ablation technique and linear ablation technique. J Am Coll Cardiol 1996; 27: 860–868.[Abstract]
[4] Fischer B, Jaïs P, Shah D, et al. Radiofrequency catheter ablation of common atrial flutter in 200 patients. J Cardiovasc Electrophysiol 1996; 7: 1225–1233.[ISI][Medline]
[5] Nakagawa H, Lazzara R, Khastgir T, et al. Role of the tricuspid annulus and the eustachian valve/ridge in atrial flutter. Circulation 1996; 94: 407–424.
[6] Poty H, Saoudi N, Abdelazziz A, Nair M, Letac B. Radiofrequency catheter ablation of type I atrial flutter: prediction of late success by electrophysiological criteria. Circulation 1995; 92: 1389–1392.
[7] Lesh MD and Kalman JM. To fumble flutter or tackle "tach"? Toward updated classifiers for atrial tachyarrhythmias. J Cardiovasc Electrophysiol 1996; 7: 460–466.[ISI][Medline]
[8] Saoudi N, Nair M, Abdelazziz A, et al. Electrocardiographic patterns and results of radiofrequency catheter ablation of clockwise type I atrial flutter. J Cardiovasc Electrophysiol 1996; 7: 931–942.[ISI][Medline]
[9] Cauchemez B, Haïssaguerre M, Fisher B, Thomas O, Clementy J, Coumel P. Electrophysiological effects of catheter ablation of inferior vena cava-tricuspid annulus isthmus in common atrial flutter. Circulation 1996; 93: 284–294.
[10] Cosio FG, Lopez-Gil M, Goicolea A, Arribas F, Barroso JL. Radiofrequency ablation of inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol 1993; 71: 705–709.[CrossRef][ISI][Medline]
[11] Schartzman D, Callans DJ, Gottlieb CD, Dillon SM, Movsowitz C, Marchlinski FE. Conduction block in the inferior vena cava-tricuspid valve isthmus: association with outcome of radiofrequency ablation of type I atrial flutter. J Am Coll Cardiol 1996; 28: 1519–1531.[Abstract]
[12] Calkins H, Leon AR, Deam AG, Kalbfleisch SJ, Langberg JJ, Morady F. Catheter ablation of atrial flutter using radiofrequency energy. Am J Cardiol 1994; 73: 353–356.[CrossRef][ISI][Medline]
[13] Kalman JM, Olgin JE, Saxon LA, Lee RJ, Scheinman MM, Lesh MD. Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man: use of activation and entrainment mapping and implications for catheter ablation. J Cardiovasc Electrophysiol 1997; 8: 121–144.[ISI][Medline]
[14] Gomes AJ, Santoni-Rugiu F, Mehta D, Langan NM, Marx SO, Nayak H. Uncommon atrial flutter: characteristics, mechanisms and results of ablative therapy. Pacing Clin Electrophysiol 1998; 21: 2029–2042.[CrossRef][Medline]
[15] Scheinman MM, Cheng J, Yang Y. Mechanism and clinical implications of atypical atrial flutter. J Cardiovasc Electrophysiol 1999; 10: 1153–1157.[ISI][Medline]
[16] Roithinger FX, Karch MR, Steiner PR, SippensGroenewegen A, Lesh MD. Relationship between atrial fibrillation and typical atrial flutter in humans: activation sequence changes during spontaneous conversion. Circulation 1997; 96: 3484–3491.
[17] Ortiz J, Niwano S, Abe H, Rudy Y, Johnson NJ, Waldo AL. Mapping the conversion of atrial flutter to atrial fibrillation and atrial fibrillation to atrial flutter: insights into mechanisms. Circ Res 1994; 74: 882–894.
[18] Saoudi N, Cosio F, Waldo SA, et al. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and atrial bases. Eur Heart J 2001; 22: 1162–1182.
[19] Roithinger F, SippensGroenewegen A, Karch M, Steiner PR, Ellis WS, Lesh MD. Organized activation during atrial fibrillation in man: endocardial and electrocardiographic manifestations. J Cardiovasc Electrophysiol 1998; 9: 451–461.[ISI][Medline]
[20] Watson RM and Josephson ME. Atrial flutter: electrophysiologic substrates and modes of initiation and termination. Am J Cardiol 1980; 45: 732–740.[CrossRef][ISI][Medline]
[21] Riva S, Tondo C, Carbucicchio C, Galimberti P, Fassini G, Della Bella P. Incidence and clinical significance of transformation of atrial fibrillation to atrial flutter in patients undergoing long-term antiarrhythmic drug treatment. Europace 1999; 1: 242–247.
[22] Murdock CJ, Kyles AE, Yeung-Lai-Wah JA, Qi A, Vorderbrugge S, Kerr CR. Atrial flutter in patients treated for atrial fibrillation with propafenone. Am J Cardiol 1990; 66: 755–757.[CrossRef][ISI][Medline]
[23] Brembilla-Perrot B and Terrier de la Chaise A. Provocation of supraventricular tachycardias by an intravenous class I antiarrhythmic drug. Int J Cardiol 1992; 34: 189–198.[Medline]
[24] Nabar A, Rodriguez LM, Timmermans C, Van den Dool A, Smeets JLRM, Wellens HJJ. 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. Circulation 1999; 99: 1441–1445.
[25] Jaïs P, Haïssaguerre M, Shah D, et al. A new electrophysiologic substrate for spontaneous left atrial flutter (abstr.). Circulation 1998; 98: 1–19.
[26] Huang DT, Monahan KM, Zimetbaum P, Papageorgiou P, Epstein LM, Josephson ME. Hybrid pharmacologic and ablative therapy: a novel and effective approach for the management of atrial fibrillation. J Cardiovasc Electrophysiol 1998; 9: 462–469.[ISI][Medline]
[27] Bogun F, Bender G, Li YG, Hohnloser SH. Ablation of atypical atrial flutter guided by the use of concealed entrainment in patients without prior cardiac surgery. J Cardiovasc Electrophysiol 2000; 11: 136–145.[ISI][Medline]
[28] Natale A, Richey M, Tomassoni GF, et al. Clinical characteristics and ablation of left side atrial flutter (abstr.). J Am Coll Cardiol 1999; 33: 116A.
[29] Kall J, Rubenstein DS, Kopp DE, et al. Atypical atrial flutter originating in the right atrial free wall. Circulation 2000; 101: 270–279.
[30] Lai LP, Lin JL, Tseng CD, Huang SK. Electrophysiologic study and radiofrequency catheter ablation of isthmus-independent atrial flutter. J Cardiovasc Electrophysiol 1999; 10: 728–735.[Medline]
[31] Olgin JE, Jayachandran VJ, Engesstein E, Groh W, Zipes DP. Atrial macroreentry involving the myocardium of the coronary sinus: a unique mechanism for atypical flutter. J Cardiovasc Electrophysiol 1998; 9: 1094–1099.[ISI][Medline]
[32] Arruda M, Widman L, Antz M, et al. Myocardial continuity between right atrium and left atrium via the coronary sinus. J Am Coll Cardiol 1997; 29: 358A.
[33] Chauvin M, Marcellin L, Douchet M, et al. Muscular connections between right and left atria in the coronary sinus in humans: anatomo-pathologic observations (abstr.). Pacing Clin Electrophysiol 1998; 21: 816.
[34] Cheng J, Cabeen WR Jr, Scheinman MM. Right atrial flutter due to lower loop reentry: mechanisms and anatomic substrates. Circulation 1999; 99: 1700–1705.
[35] Cheng J and Scheinman MM. Acceleration of typical atrial flutter due to double-wave reentry induced by programmed electrical stimulation. Circulation 1998; 97: 1589–1596.
[36] Shah DC, Jaïs P, Haïssaguerre M, et al. Three-dimensional mapping of the common atrial flutter in the right atrium. Circulation 1997; 96: 3904–3912.
[37] Shah DC, Haïssaguerre M, Jaïs P, Takahashi A, Hocini M, Clementy J. High-density mapping of activation through an incomplete isthmus ablation line. Circulation 1999; 99: 211–215.
[38] Friedman PA and Stanton MS. Spot welding the gap in atrial flutter ablation. Circulation 1999; 99: 3206–3208.
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