3/3/2010

BY
Dr. Rania samir
Lecturer off Cardiology
d l
Ain Shams University

Š Atrial flutter represents the most important &

most common atrial tachyarrhythmia after AF

Š The re-entry circuits often occupy large areas

of the atrium & are referred to as “macro
macro-
reentrant”

Š The overall incidence of atrial flutter in a

recent population study was 0.88%,
0.05% in patients < 50 years old
5.87% among individuals > 80 years of age.

(Granada et al, 2000)

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Š Many different forms of atrial flutter exist & since it

was first described in 1911,
1911 many terms have been
used to characterize atrial flutter, particularly
recently, to the point that atrial flutter terminology
has become quite confusing

Š This has led to multiple classification schemes.

schemes

Š First simple classification based on ECG patterns, in

1970
yp
-Typical 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

Isthmus dependent Non-Isthmus dependent

Atypical atrial flutter
atrial flutter atrial flutter

The re-entry circuit is any fixed Type II atrial flutter

confined to RA & involves
the CTI as a critical zone of
slow conduction
• CCW A. flutter
(commonest 90%)
• CW A. flutter (less
commom 10%)
• Lower loop re-entrry
macroreentrant atrial
heterogenous flutter
circuit that doesn’t
wave morphology
involve the CTI
May be due to rapid
y with
reentry
variable fib.
• Lesion macroreentrant Conduction
atrial tachycardia (most
common)
• upper loop reentry
• LA flutter (rare)
ACC/AHA/ESC Guidelines 2003

Š isthmus dependent atrial

flutter was determined to be
due to a macroreentrant
circuit rotating in either a CT
counterclockwise
(common) or clockwise IAS
(uncommon) direction in
th right
the i ht atrium,
ti with
ith an CS
area of relatively slow ER
IVC
conduction in the low TA
posterior right atrium

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Š Atrial flutter is most often a nuisance arrhythmia & its

clinical significance lies largely in its frequent
association with AF or rapid ventricular response
which is principally responsible for many of the
associated symptoms So, maintenance of SR after
CV is mandatory in cases of recurrent A.flutter

Š Based on the available long term data

data, drug treatment
offered a limited ability to maintain SR without
occasional to frequent recurrences of A.flutter, even
when multiple agents are used.

Š Reported long term success rates ranging from 50% for

class I to 73% for class III (oral dofetilide)

Š Also, long-term rate control alone usually requires large

doses of AV nodal blocking agents

Singh et al, Circulation 2000

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Š Approaches to endocardial mapping of A flutter

include standard multielectrode catheters, Expanding
electrode
l t d arrays or 3D mapping i ttechniques
h i b
butt still
till
Standard multielectrode catheter-based mapping still
remains the main tool for the study of A flutter

Š The recent advances in this therapeutic

approach h were associated
i t d with
ith high
hi h success
rates, low recurrence rates and minimal
complications.

LAO LAO

IAS

IAS

Isthm
IVC

Isthm

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Large randomized trials, RF- ablation creating linear lesions

across the critical zone of slow conduction (CTI) till achievement
off CBIB as an endpoint
d i t off ablation
bl ti

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)

LAO RAO

Ain Shams University EP lab

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Complete CW block
During PCS pacing
Before ablation After ablation
Ain Shams University EP lab

LRA pacing Complete CCW block

Before ablation After ablation

Ain Shams University EP lab

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Š Variation in the isthmus width

Isthmus width 17-54 mm
g <81°
Isthmus width > 39 mm or Cath-IVC angle assoc with difficuilty
y of
reaching TA

Wide isthmus (49 mm) Craniocaudally elongated

making sharp angle RA with short isthmus (17
with IVC 79° mm) Heidbüchel et al Circulation 2000

Š Variations in morphological features:

Prominent thick EV (20%)

of pts causing difficulty in
reaching behind EV
needing abl cath with
shorter curve
pouch like recess (varying from 1.5 to
9.4 mm deep), > 5mm deep pouch
Heidbüchel et al Circulation 2000
In ≈50% of pts the isthmus has global
concave morphology (A)
In ≈ 45% of pts the isthmus is divided
into flat smooth vestibule near TA
side & pouch like recess near IVC
side (4.3±2.1 mm)

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Comparing the published success rates of AADs in

maintaining SR to significantly high long term success rates
of RF-ablation Favors RF ablation as an acceptable
therapeutic approach of A . flutter

ACC/AHA/ESC guidelines,2003

Š Although the success rates of RF-ablation

using conventional & 3D mapping techniques
are similar

Š Shorter fluoroscopy time (3.9±15 vs 22 ±6.3 min)

(Kottkamp et al, 2000)
Š Precise identification of discrete gaps within
non-contiguous lesion lines the ability to
renavigate to previously mapped & ablated
sites
Š Fast & reliable identification of WSDP along
the ablation line

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TCL 240 ms
Ain Shams University EP lab

CS pacing after ablation CS pacing before ablation

showing CW isthmus block
Ain Shams University EP lab

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Before ablation
After ablation
Ain Shams University EP lab

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Š Isthmus ablation in patients with atrial flutter has

proved positive impact on QOL.

Š Catheter ablation is curative in many patients

obviating the need for life-long AADs, and may be
more cost effective on the long term than AAD
therapy.

Š Substantial fluoroscopy exposure, which is necessary

f conventional
for ti l isthmus
i th ablation,
bl ti iis significantly
i ifi tl
reduced with 3D mapping for isthmus ablation which
have an impact on the long-term safety of this invasive
treatment strategy.

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