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. 1999 Jan;81(1):73–81. doi: 10.1136/hrt.81.1.73

Electrophysiological determinant for induction of isthmus dependent counterclockwise and clockwise atrial flutter in humans

J Lin 1, L Lai 1, L Lin 1, Y Tseng 1, W Lien 1, S Huang 1
PMCID: PMC1728902  PMID: 10220549

Abstract

Objective—To investigate the electrophysiological determinant underlying the electrical induction of counterclockwise and clockwise isthmus dependent atrial flutter.
Patients and methods—The isthmus bordered by the inferior vena caval orifice-tricuspid annulus-coronary sinus ostium (IVCO-TA-CSO) has been assumed to be the site of both slow conduction and unidirectional block critical to the initiation of atrial flutter. Trans-isthmus and the global atrial conduction were studied in 25 patients with isthmus dependent atrial flutter (group A) and in 21 patients without atrial flutter (group B), by pacing at the coronary sinus ostium and the low lateral right atrium (LLRA) and mapping with a 20 pole Halo catheter in the right atrium.
Results—Mean (SD) fluoroscopic isthmus length between the coronary sinus ostium and LLRA sites was 28.1 (4.0) mm in group A and 28.0 (3.9) mm in group B (p = 0.95), but the trans-isthmus conduction velocity of both directions at various pacing cycle lengths was nearly halved in group A compared with group B (mean 0.39-0.46 m/s v 0.83-0.89 m/s, p < 0.0001). Pacing at coronary sinus ostium directly induced counterclockwise atrial flutter in 14 patients and pacing at LLRA induced clockwise atrial flutter in 11 patients, following abrupt unidirectional trans-isthmus block. Transient atrial tachyarrhythmias preceded the onset of atrial flutter in 10 counterclockwise and six clockwise cases of atrial flutter. None of the group B patients had inducible atrial flutter even in the presence of trans-isthmus block. The intra- and interatrial conduction times, as well as the conduction velocities at the right atrial free wall and the septum, were similar and largely within the normal range in both groups.
Conclusions—Critical slowing of the trans-IVCO−TA−CSO isthmus conduction, but not the unidirectional block or the global atrial performance, is the electrophysiological determinant of the induction of counterclockwise and clockwise isthmus dependent atrial flutter in man.

 Keywords: atrial flutter;  electrical induction;  radiofrequency catheter ablation

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Figure 1  .

Figure 1  

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Orthogonal fluoroscopic views showing the positions of the 20 pole Halo catheter and the two pacing electrodes at the low lateral right atrium (LLRA) and coronary sinus ostium (CSO). On the left is the 60° left anterior oblique (LAO) view, and on the right is the 30° right anterior oblique (RAO) view. As shown, the Halo 1 to Halo 5 bipoles are to map the anterolateral free wall of right atrium, while Halo 6 to Halo 10 bipoles map the septum. Another coronary sinus catheter is in the position for guiding the location of the coronary sinus ostium and for mapping the interatrial conduction. The isthmus length (the dotted line between the tips of the two deflectable catheters at the LLRA and CSO) in the IVCO-TA-CSO region was 28 mm in the 60° LAO view.

Figure 2  .

Figure 2  

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Demonstration of entrainment with concealed fusion by pacing at the coronary sinus ostium (CSO) for counterclockwise atrial flutter (A) and by pacing at the LLRA for clockwise atrial flutter (B). Note the mainly negative flutter wave in the inferior ECG leads for counterclockwise atrial flutter and the mainly positive flutter wave for clockwise atrial flutter. Neither the surface ECG nor the intra-atrial activation sequence in (A) and (B) show evidence of fusion or wavefront collision. The demonstration of entrainment with concealed fusion indicates the collision or block of the antidromic pacing wavefront inside the slow conduction zone of the atrial flutter circuit. The short stimulus to onset of the ECG flutter wave interval in both situations indicates that the coronary sinus ostium was the exit of the slow conduction zone in counterclockwise atrial flutter and the low lateral right atrium was the exit in clockwise atrial flutter. The onset of the flutter wave was recognised as the beginning of the downward deflection of the saw tooth morphology of the flutter wave since the IVCO-TA-CSO isthmus is located in the low right atrium. The cycle length of the counterclockwise atrial flutter (A) was 226 ms, and that of the clockwise atrial flutter (B) was 217 ms. The asterisk indicates the last entrained beat.

Figure 3  .

Figure 3  

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The retrograde right atrial (RA) activation sequence of Halo catheter mapping by low lateral right atrium (LLRA) pacing (left two panels) and coronary sinus ostium (CSO) pacing (right two panels) in sinus rhythm in a patient with atrial flutter (atrial flutter +) and a patient without atrial flutter (atrial flutter −). Note that in the patient without atrial flutter, the collision site of the RA free wall and RA septal wavefronts is at Halo 5. However, in the patient with atrial flutter, the collision site shifts to Halo 7 during LLRA pacing and to Halo 3 during coronary sinus ostium pacing. S, pacing spike. The pacing cycle length was 250 ms, and the paper speed was 100 mm/s in all four panels.

Figure 4  .

Figure 4  

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Induction of counterclockwise atrial flutter by pacing at the coronary sinus ostium site at the cycle length of 240 ms. Note the abrupt unidirectional block across the isthmus (between Halo 1 and 10) and the initiation of the counterclockwise atrial flutter (cycle length 244 ms), after repenetration of the right atrial wavefront from the low lateral right atrial end to the coronary sinus ostium end of the isthmus. (See diagram.) CSOP, coronary sinus ostium pacing; CT, crista terminalis; ER, eustachian ridge; S, pacing spike. The asterisk indicates the pacing site.

Figure 5  .

Figure 5  

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Induction of clockwise atrial flutter by pacing at the low lateral right atrial (LLRA) site at the cycle length of 200 ms. Note the abrupt unidirectional block between Halo 1 and Halo 10 (that is, the isthmus zone) and the initiation of clockwise atrial flutter (cycle length 224 ms) after repenetration of the right atrial wavefront from the coronary sinus ostium end to the LLRA end of the isthmus. (See diagram.) CT, crista terminalis; ER, eustachian ridge; LLRAP, LLRA pacing; S, pacing spike.

Figure 6  .

Figure 6  

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Induction of clockwise atrial flutter by pacing from the coronary sinus ostium site after a transient episode of multifocal atrial premature beats (indicated by dots). The pacing cycle length was 220 ms. The cycle length of clockwise atrial flutter was 266 ms. The asterisks indicate the first beat of the sustained clockwise atrial flutter.

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