The definition of atypical atrial flutter includes a broad spectrum of other macroreentrant tachycardias in which the wave front does not travel around the tricuspid annulus.Ītypical right atrial flutter other than reverse typical atrial flutter, includes the following: lower loop reentry, fosa ovalis flutter, superior vena cava flutter and upper loop reentry (Figure 2). Acute success rate is almost 95% in the registries.(1) However, at 5 year follow-up almost 70% of these patients might develop atrial fibrillation or atypical atrial flutter, which is probably related to the baseline characteristics, structural heart disease and uncontrolled risk factors. See here, previous article on flutter’s differential diagnoses and treatment approaches). (For a closer look at ablation, see previous e-journal articles on rhythmologist's view on the patient after the procedure, or surgeons' look at procedure in lone atrial fibrillation. The ablation procedure's main target is to achieve bidirectional block through the cavotricuspid isthmus (CTI). After the first episode of AFL-I (Class IIa indication), especially in those presenting with poor hemodynamic tolerance or tachymiocardiopathy.In AFL-I recurrences despite medical treatment (Class I indication).(6,7)Įlectrophysiological studies (EPs) are indicated: In the second case, a regular irregularity has to be always ruled out. In the first case, vagal maneuvers or AV node blocking drugs, such as adenosine, may be useful. Both high and irregular ventricular rate responses may make the diagnosis difficult.Concomitant circuits could also change the typical atrial appearance.Scarred atria with low areas of voltage could mimic isoelectric baseline despite atrial continuous electrical activity.Some conditions may make the ECG diagnosis difficult: The electrocardiogram shows a saw tooth's pattern in inferior leads, with a slow downward slope followed by a fast upward slope explained by electrical forces going through the cavotricuspid isthmus and the septum, and then approaching the inferior leads through the lateral wall (Figure 1).(4,5) This saw tooth’s appearance could be easily registered when the ventricular rate response is controlled. The wave front may rotate around this circuit counterclockwise (most frequently) or clockwise, resulting in the counterclockwise common atrial flutter or the clockwise atrial flutter, respectively.(4,5) This condition produces continuous electrical activity around the atrial circuit and consequently in the electrocardiogram (f waves). Typical atrial flutter originates in a well-known circuit around the tricuspid annulus limited by anatomical barriers such as both the superior and inferior cava veins, the coronary sinus and crista terminalis. (4) Ventricular rate response will be limited by the atrioventricular (AV) node conductions, usually presenting a 2:1 or 3:1 response, during atrial flutter. This arrhythmia has a 200-260 ms cycle length, although it may fluctuate depending on patient's previous treatment or ablation, congenital heart disease, etc. It can also be defined as a macroreentrant tachycardia confined to the right atrium. Typical atrial flutter is an organised atrial tachycardia. We present a brief report describing common atrial flutter as well as the main atypical forms, with a focus on description of their circuits, and main electrocardiographic patterns.

Loss of atrioventricular synchronisation and physiological rate response to activity can also decrease functional class in patients with ventricular dysfunction. In patients with chronic obstructive pulmonary disease with concomitant bronchodilators especially, controlling the ventricular rate could be challenging with an increased risk of 1:1 ventricular response. Typical atrial flutter cases (AFL-I) make up 22% of all 8,546 ablation procedures in the Spanish National Ablation's Registry (behind atrioventricular nodal reentrant tachycardia, accessory pathways but ahead of atrial fibrillation).įurthermore, atrial flutter is considered to hold as much risk as atrial fibrillation for thromboembolic events (3-4% per year).(2,3) Atrial flutter also carries a proarrhythmic risk, and additionally, rhythm control and ventricular rate response can only hardly be achieved with medical treatment.

Paroxysmal atrial flutter icd 10