Typical Atrial Flutter. Matt Wright St. Thomas Hospital London
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1 Typical Atrial Flutter Matt Wright St. Thomas Hospital London
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3 Typical Right Atrial Cavotricuspid Dependent Flutter A macro re-entrant arrhythmia Anatomical barrier Zone of slow conduction Typical CTI Dependent atrial flutter Contained within the right atrium Constrained anteriorly by the tricuspid valve Constrained posteriorly by the crista terminalis and eustachian ridge Travels in a counterclockwise direction around the atrium
4 Atrial Flutter
5 Atrial Flutter
6 Atrial Flutter: Activation Mapping
7 Atrial Flutter: Positioning Catheters
8 Atrial Flutter: Anatomy
9 Confirmation of Diagnosis Careful examination of the surface ECG If suspected: low to high activation of septum high to low activation of the lateral wall CS activation proximal to distal, earlier than His A Entrainment Two disparate sites within the circuit (PPI-TCL <30ms) On the isthmus- concealed entrainment
10 Atrial Flutter: Lesion
11 Endpoint: Bidirectional Conduction Block After RF terminates atrial flutter conduction through the isthmus often persists Conduction slowing often occurs before isthmus block conduction slowing can be rate dependent Recovery of conduction after initial isthmus block is common Schwartzman et al J Am Coll Cardiol 1996; 28:1519 Shah et al J Am Coll Cardiol 2000; 35: 1478
12 Differential Pacing
13 Double Potentials Tada JACC 2001;38:750
14 Markers of Conduction Block increase in trans-isthmus conduction time differential pacing double potentials ms interval between potentials along entire ablation line differential pacing reversal of electrogram polarity on the opposite side of the ablation line from the pacing site change in p-wave morphology pacing lateral to the ablation line Tada JACC 2001;38:750. Tai JICE 2002;7:77. Chen JICE 2002;7:67. Tada JCE 2001;12:393. Shah JCE 1999;10:662. Circ 1997;96:2505. Nakagawa Circ 1996;94:3204. Poty Circ 1996;94:3204
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18 Plateau Rapid descent
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21 Differential Pacing: Lateral
22 Differential Pacing: Closer to Line
23 Differential Pacing: On the line 130ms
24 Drug therapy vs first-line ablation for atrial flutter 61 patients > 1 episode of atrial flutter no prior antiarrhythmic drug therapy Antiarrhythmic Drug Therapy sotalol, amiodarone flecainide, procainamide, propafenone RF Ablation > 90% reduction in electrogram amplitude along ablation line Atrial Flutter Recurrence: Atrial Fibrillation: Sinus rhythm last f/u mean follow-up: 22 months 93% 60% 36% 6% 29% 80% Natale et al J Am Coll Cardiol 2000
25 Results Meta-analysis of 10 year period (10719 pts) Acute success rate of 91% and 88% (8mm vs irrigated) Recurrence rates 9% with bidirectional block vs 24% Atrial Fibrillation seen 34% patients during follow up Previous AF 53%; new diagnosis 23% Pérez et al. Circulation EP 2009
26 Summary Catheter ablation is first line therapy for typical flutter It s a macro-reentrant tachycardia Activation and entrainment maneuvres are used to confirm the diagnosis Long term success rates > 90% Bidirectional block not termination of flutter is the endpoint Atrial Fibrillation seen 34% patients during follow up
27 Matt Wright MRCP PhD Cardiac Electrophysiology Rayne Institute Department of Cardiology St. Thomas' Hospital Westminster Bridge Road London SE1 7EH United Kingdom
28 Atrial Flutter
29 Atrial Flutter
30 Atrial Flutter
31 Atrial Flutter: Anatomy
32 Atrial Flutter
33 Pitfalls Assessing Block
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