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Revista Portuguesa de Cardiologia :... Apr 2023Ablation of atypical left atrial flutters (LAF) is very challenging due to the complexity of the underlying atrial substrate and diverse arrhythmia mechanisms. The...
Ablation of atypical left atrial flutters (LAF) is very challenging due to the complexity of the underlying atrial substrate and diverse arrhythmia mechanisms. The interpretation of the arrhythmia mechanism is usually difficult, even using advanced three-dimensional (3D) mapping systems. SparkleMap is a novel mapping algorithm that displays each electrogram as a green dot that lights up at the point corresponding to the local activation time, superimposed either on the substrate or the local activation time 3D-maps. It is not affected by the setting of the "window of interest" and there is no need for user post-processing. We present the case of patient with a persistent atypical LAF in whom we tested the concept of complex arrhythmia interpretation exclusively based on the analysis of the substrate and evaluation of SparkleMap-derived wavefront propagation. We describe the workflow for map collection and the systematic approach for arrhythmia interpretation that resulted in the identification of a dual loop perimitral mechanism with a common slow conducting isthmus inside a scar at the septum/anterior atrial wall. This new method of analysis enabled the use of a specifically targeted and precise approach for ablation, with restoration of sinus rhythm within five seconds of radiofrequency application. After 18 months of follow-up, the patient remains free from recurrences, without anti-arrhythmic medication. This case report exemplifies how helpful new mapping algorithms can be in the interpretation of the arrhythmia mechanism in patients with complex LAF. It also suggests an innovative workflow to integrate the SparkleMap into the mapping approach.
Topics: Humans; Atrial Flutter; Atrial Fibrillation; Catheter Ablation; Heart Atria; Atrial Appendage; Treatment Outcome
PubMed: 36893834
DOI: 10.1016/j.repc.2020.08.015 -
Clinical Cardiology Mar 1992The electrophysiologic substrates of atrial flutter and fibrillation (AFF) have been studied in patients with paroxysmal arrhythmias. Atrial repetitive responses to... (Review)
Review
The electrophysiologic substrates of atrial flutter and fibrillation (AFF) have been studied in patients with paroxysmal arrhythmias. Atrial repetitive responses to extrastimuli are a nonspecific response, even though they can precipitate AFF. AFF inducibility is rather sensitive, but not very specific, in separating patients from controls. There is no established protocol to explore vulnerability in this fashion. Atrial refractoriness is abnormal in some patients. Some authors have found a tendency toward short effective refractory periods (AERP) and others have found a poor adaptation of AERP to decreases in cycle length. Unfortunately, these abnormalities are neither sensitive nor specific enough. Atrial conduction may be abnormal basally, but subtler abnormalities are shown by premature stimulation. Early extrastimuli are conducted with increased conduction delays in patients with paroxysmal AFF in relation to controls. Again, there is not enough sensitivity and specificity in the findings to make them of diagnostic value. Electrophysiologic abnormalities are detectable in patients with AFF, but larger studies, including reproducibility and the effect of drugs on the abnormal parameters, will be necessary to develop clinical applications.
Topics: Atrial Fibrillation; Atrial Flutter; Heart Conduction System; Humans
PubMed: 1551267
DOI: 10.1002/clc.4960150311 -
Open Heart Jan 2021Cavo-tricuspid isthmus atrial flutter (CTI-AFL) is an important arrhythmia to recognise because there is a highly effective and relatively low-risk ablation strategy.... (Review)
Review
OBJECTIVE
Cavo-tricuspid isthmus atrial flutter (CTI-AFL) is an important arrhythmia to recognise because there is a highly effective and relatively low-risk ablation strategy. However, clinical experience has demonstrated that providers often have difficulty distinguishing AFL from atrial fibrillation.
METHODS
We developed a novel ECG-based three-step algorithm to identify CTI-AFL based on established CTI flutter characteristics and verified on consecutive ablation cases of typical flutter, atypical flutter and atrial fibrillation. The algorithm assesses V1/inferior lead F-wave concordance, consistency of P-wave morphology and the presence of isoelectric intervals in the inferior leads. In this observation study, the algorithm was validated on a cohort of 50 second-year medical students. Students were paired in a control and experimental group, and each pair received 10 randomly selected ECGs (from a pool of 50 intracardiac electrogram-proven CTI-AFL and 50 AF or atypical AFL cases). The experimental group received a cover sheet with the CTI algorithm, and the control group received no additional guidance.
RESULTS
There was a statistically significant difference in the mean number of correctly identified ECGs among the students in the experimental and control groups (8.12 vs 5.68, p<0.001). Students who used the algorithm correctly identified 2.44 more ECGs as being CTI-AFL or not CTI-AFL. Using the electrophysiology study as the gold standard, the algorithm had an accuracy of 81%, sensitivity of 81%, specificity of 82%, positive predictive value of 78% and negative predictive value of 84% in identifying CTI-AFL.
CONCLUSION
We developed a three-step ECG algorithm that provides a simple, sensitive, specific and accurate tool to identify CTI-AFL.
Topics: Algorithms; Atrial Flutter; Electrocardiography; Electrophysiologic Techniques, Cardiac; Heart Conduction System; Humans; Tricuspid Valve
PubMed: 33504631
DOI: 10.1136/openhrt-2020-001431 -
Heart Failure Reviews Jul 2023Atrial fibrillation (AF) and atrial flutter (AFL) are associated with adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF). We... (Review)
Review
Association between sodium-glucose cotransporter-2 inhibitors and incident atrial fibrillation/atrial flutter in heart failure patients with reduced ejection fraction: a meta-analysis of randomized controlled trials.
Atrial fibrillation (AF) and atrial flutter (AFL) are associated with adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF). We investigated the effects of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on the incidence of AF and/or AFL in HFrEF patients. PubMed and ClinicalTrials.gov were systematically searched until March 2022 for randomized controlled trials (RCTs) that enrolled patients with HFrEF. A total of six RCTs with 9467 patients were included (N = 4731 in the SGLT2i arms; N = 4736 in the placebo arms). Compared to placebo, SGLT2i treatment was associated with a significant reduction in the risk of AF [relative risk (RR) 0.62, 95% confidence interval CI 0.44-0.86; P = 0.005] and AF/AFL (RR 0.64, 95% CI 0.47-0.87; P = 0.004). Subgroup analysis showed that empagliflozin use resulted in a significant reduction in the risk of AF (RR 0.55, 95% CI 0.34-0.89; P = 0.01) and AF/AFL (RR 0.50, 95% CI 0.32-0.77; P = 0.002). By contrast, dapagliflozin use was not associated with a significant reduction in the risk of AF (RR 0.69, 95% CI 0.43-1.11; P = 0.12) or AF/AFL (RR 0.82, 95% CI 0.53-1.27; P = 0.38). Additionally, a "shorter" duration (< 1.5 years) of treatment with SGLT2i remained associated with a reduction in the risk of AF (< 1.5 years; RR 0.58, 95% CI 0.36-0.91; P = 0.02) and AF/AFL (< 1.5 years; RR 0.52, 95% CI 0.34-0.80; P = 0.003). In conclusion, SGLT2i therapy was associated with a significant reduction in the risk of AF and AF/AFL in patients with HFrEF. These results reinforce the value of using SGLT2i in this setting.
Topics: Humans; Atrial Fibrillation; Atrial Flutter; Treatment Outcome; Randomized Controlled Trials as Topic; Heart Failure; Ventricular Dysfunction, Left; Glucose; Sodium
PubMed: 36282460
DOI: 10.1007/s10741-022-10281-3 -
Herzschrittmachertherapie &... Sep 2022In contrast to typical atrial flutter, atypical atrial flutter is a heterogeneous group of right and left atrial macro- or localized reentry tachycardias whose critical...
In contrast to typical atrial flutter, atypical atrial flutter is a heterogeneous group of right and left atrial macro- or localized reentry tachycardias whose critical component for maintaining tachycardia is not the cavotricuspid isthmus. Atypical atrial flutter occurs more frequently after previous catheter ablation and after cardiac surgery. The intraprocedural success rate during ablation is high, although the recurrence rate depends on structural changes in the atria as well as the underlying mechanism. This article provides an overview of the mechanisms as well as mapping and ablation strategies of the most common forms of right and left atrial atypical atrial flutter. This article is part of the "EP Basics" series for targeted continuing education in invasive electrophysiology. Basics, clinic and therapy of atypical atrial flutter are presented with focus on clinically relevant aspects. Procedures and findings of invasive electrophysiological diagnostics and ablation treatment are the focus of this article.
Topics: Atrial Fibrillation; Atrial Flutter; Catheter Ablation; Heart Atria; Humans; Tachycardia
PubMed: 35986095
DOI: 10.1007/s00399-022-00887-3 -
The Turkish Journal of Pediatrics 2018Yılmaz-Semerci S, Bornaun H, Kurnaz D, Cebeci B, Babayiğit A, Büyükkale G, Çetinkaya M. Neonatal atrial flutter: Three cases and review of the literature. Turk J... (Review)
Review
Yılmaz-Semerci S, Bornaun H, Kurnaz D, Cebeci B, Babayiğit A, Büyükkale G, Çetinkaya M. Neonatal atrial flutter: Three cases and review of the literature. Turk J Pediatr 2018; 60: 306-309. Atrial flutter (AFl) is known to be a seldom type of fetal and neonatal arrhythmia. Although it could end in severe morbidities such as hydrops fetalis or even death, with early prenatal diagnosis and prompt therapeutic approaches the majority of AFl cases show good prognosis. Neonatal AFl might be resistant to first step therapies. Therefore, secondary agents like flecainide, amiodarone, sotalol and cardioversion, if required, could be influent in perinatal tachyarrhythmia. In addition, close follow-up even after discharge is very important to keep all follow-up appointments. Herein, we present three cases of fetal/neonatal AFl in light of the literature and discuss the characteristics, diagnosis and treatment options.
Topics: Anti-Arrhythmia Agents; Atrial Flutter; Electric Countershock; Electrocardiography; Female; Humans; Infant, Newborn; Male; Pregnancy; Ultrasonography, Prenatal
PubMed: 30511544
DOI: 10.24953/turkjped.2018.03.011 -
Atrial Arrhythmia Ablation in Patients With D-Transposition of the Great Arteries and Atrial Switch.Circulation. Arrhythmia and... Jul 2022Patients with D-transposition of the great arteries and atrial switch have a high incidence of atrial arrhythmias. We sought to analyze the arrhythmia substrate,...
BACKGROUND
Patients with D-transposition of the great arteries and atrial switch have a high incidence of atrial arrhythmias. We sought to analyze the arrhythmia substrate, ablation strategies, and outcomes for catheter ablation in this population.
METHODS
An in-depth analysis of all clinical and procedural data in patients with D-transposition of the great arteries, atrial baffles, and atrial arrhythmia ablation was performed.
RESULTS
A cohort of 32 patients (72% male, mean age 38±7 years) underwent ablation for non-AV nodal reentrant tachycardia atrial arrhythmias, and 4 patients underwent AV nodal reentrant tachycardia ablation. Cavotricuspid isthmus flutter (CTI-flutter) was the most common arrhythmia, encountered in 75% of patients, followed by scar-related intraatrial reentrant tachycardia (non-CTI intraatrial reentrant tachycardia, 53%) and focal atrial tachycardia (focal atrial tachycardia, 6%). Among the 32 patients, 26 underwent 31 procedures at our institution. For patients with prior outside intervention, the index ablation at our institution revealed CTI-dependent flutter in 3/5 cases. However, redo ablation after an index ablation with demonstrated bidirectional CTI block revealed different/new arrhythmia substrates (80% non-CTI intraatrial reentrant tachycardia, 40% focal atrial tachycardia). Achieving bidirectional block across the CTI often required ablating on both sides of the baffle (retroaortic access, 81%; using a baffle leak, 11.5%; or transbaffle puncture, 7.7%). Combined approaches were necessary in 19% to reach the critical tissue. Acute procedural success was 81%, and recurrence was documented in 58% of patients. Despite recurrence, clinical arrhythmia burden was significantly reduced post-ablation (<0.001), with rare episodes, amenable to antiarrhythmic therapy. Redo ablation was required in 5 (19%) patients and uncovered new arrhythmia substrates. AV nodal reentrant tachycardia ablation also required transbaffle approaches in 3/4 patients.
CONCLUSIONS
CTI-dependent flutter was the most common arrhythmia in patients with Dextro-Transposition of the Great Arteries and atrial switch. Transbaffle approaches were often necessary, and, provided that bidirectional CTI block was achieved at the index ablation, late recurrence was due to different arrhythmia mechanisms. Despite recurrence, ablation was associated with significant clinical improvement.
Topics: Adult; Arteries; Atrial Flutter; Catheter Ablation; Female; Humans; Male; Middle Aged; Tachycardia; Tachycardia, Atrioventricular Nodal Reentry; Tachycardia, Ectopic Atrial; Transposition of Great Vessels; Treatment Outcome
PubMed: 35763440
DOI: 10.1161/CIRCEP.121.010546 -
Journal of the American Heart... Jun 2016Atrial flutter (AFl) accounts for up to one third of all fetal tachyarrhythmias and can result in premature delivery, hydrops, and fetal death in 10% of cases; however,... (Observational Study)
Observational Study
BACKGROUND
Atrial flutter (AFl) accounts for up to one third of all fetal tachyarrhythmias and can result in premature delivery, hydrops, and fetal death in 10% of cases; however, the electrophysiology of AFl in utero is virtually unstudied.
METHODS AND RESULTS
In this observational study, we reviewed 19 fetal magnetocardiography studies from 16 fetuses: 15 fetuses (21-38 weeks' gestation) referred with an echocardiographic diagnosis of AFl and 1 fetus (20 weeks' gestation) referred with a diagnosis of tachycardia that was shown by fetal magnetocardiography to have transient AFl in addition to atrioventricular reciprocating tachycardia. Thirteen fetuses showed AFl during the fetal magnetocardiography session, including 4 that presented prior to the third trimester. Five fetuses had incessant AFl; all but 1 of the others with AFl showed additional significant rhythms. Specifically, AFl showed a strong association with rhythms involving an accessory pathway: atrioventricular reciprocating tachycardia, blocked reentrant premature atrial contractions, and ventricular preexcitation. The observed initiations and terminations of AFl most often involved reentrant premature atrial contractions. Spontaneous termination of AFl showed AFl cycle length oscillations. Nine fetuses with 2:1 AFl also showed periods of 4:1 conduction or variable conduction that oscillated between 2:1 and 4:1; however, 3:1 AFl was relatively rare.
CONCLUSIONS
Fetal AFl can occur as early as midgestation and is often accompanied by atrioventricular reciprocating tachycardia and other rhythms associated with an accessory pathway. The findings depict critical differences in the electrophysiology of AFl in the fetus versus the neonate.
Topics: Accessory Atrioventricular Bundle; Atrial Flutter; Echocardiography; Female; Fetal Diseases; Humans; Magnetocardiography; Pregnancy; Prenatal Diagnosis; Retrospective Studies; Tachycardia, Reciprocating
PubMed: 27302699
DOI: 10.1161/JAHA.116.003673 -
Journal of the American Heart... May 2024Genetic and familial contributions to early-onset atrial fibrillation are described primarily in individuals of European ancestry. However, the role of racial and...
BACKGROUND
Genetic and familial contributions to early-onset atrial fibrillation are described primarily in individuals of European ancestry. However, the role of racial and familial contributions in the pathogenesis of early-onset atrial flutter (EOAFL) is unclear.
METHODS AND RESULTS
In this cross-sectional study, participants were enrolled prospectively from 2015 to 2021 in multiple academic centers with a diagnosis of atrial flutter (AFL) confirmed by ECG. EOAFL was defined as a diagnosis of AFL before age 66 years with no concomitant or previous diagnosis of atrial tachyarrhythmias. Family history was adjudicated through baseline questionnaires and direct family interviews about the diagnosis of atrial tachyarrhythmias, stroke, and cardiomyopathy. The primary exposure was a positive family history in first-degree relatives, and the primary outcome was the odds of EOAFL versus late-onset AFL. A total of 909 patients were enrolled. Participants with a positive family history of atrial tachyarrhythmias were younger, less likely to be of Black race, and more likely to have EOAFL. The adjusted odds ratio (OR) for EOAFL in those with a positive family history was 1.8 (95% CI, 1.1-3.0). There was an increased odds of EOAFL in those of Black race (OR, 2.1 [95% CI, 1.4-3.2]), alcohol use (OR, 1.6 [95% CI, 1.0-2.6]), and obstructive sleep apnea (OR, 1.9 [95% CI, 1.0-3.4]). Use of cardioselective β blockers or calcium channel blockers before the diagnosis of AFL were associated with a lower odds of EOAFL (OR, 0.5 [95% CI, 0.2-0.9]).
CONCLUSIONS
These findings suggest a potentially hereditary predisposition to EOAFL across race and ethnicity, warranting further study of the genetic contributions to AFL.
Topics: Humans; Atrial Flutter; Female; Male; Cross-Sectional Studies; Middle Aged; Age of Onset; Risk Factors; Prospective Studies; Ethnicity; Genetic Predisposition to Disease; Aged; Adult; United States; Electrocardiography; Risk Assessment; Medical History Taking
PubMed: 38726902
DOI: 10.1161/JAHA.123.032320 -
International Journal of Cardiology Jan 2023The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity...
Atrial flutter and fibrillation in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in the ASPIRE registry: Comparison of rate versus rhythm control approaches.
BACKGROUND
The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared.
METHODS
Eighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009-13) and later (2014-19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored.
RESULTS
Sixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications.
CONCLUSIONS
Restoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.
Topics: Humans; Atrial Flutter; Hypertension, Pulmonary; Pulmonary Arterial Hypertension; Atrial Fibrillation; Electric Countershock; Familial Primary Pulmonary Hypertension; Treatment Outcome
PubMed: 36130620
DOI: 10.1016/j.ijcard.2022.09.031