Skip to main content
NCBI home page
Heart logoLink to Heart
. 2001 Apr;85(4):424–429. doi: 10.1136/heart.85.4.424

Class IC antiarrhythmic drug induced atrial flutter: electrocardiographic and electrophysiological findings and their importance for long term outcome after right atrial isthmus ablation

A Nabar 1, L Rodriguez 1, C Timmermans 1, R van Mechelen 1, H Wellens 1
PMCID: PMC1729704  PMID: 11250970

Abstract

OBJECTIVE—To describe the electrocardiographic and electrophysiological findings of new atrial flutter developing in patients taking class IC antiarrhythmic drugs for recurrent atrial fibrillation, and to report the long term results of right atrial isthmus ablation in relation to the ECG pattern of spontaneous atrial flutter.
DESIGN—Retrospective analysis.
SETTING—Tertiary care academic hospital.
PATIENTS—24 consecutive patients with atrial fibrillation (age 54 (12) years; 5 female, 19 male) developing atrial flutter while taking propafenone (n = 12) or flecainide (n = 12).
RESULTS—The ECG was classified as typical (n = 13; 54%) or atypical atrial flutter (n = 8) or coarse atrial fibrillation (n = 3). Counterclockwise atrial flutter was the predominant arrhythmia. Acute success after isthmus ablation was similar in patients with typical (12/13) and atypical (8/8) atrial flutter. After long term follow up (13 (6) months, range 6-26 months), continuation of antiarrhythmic drug treatment appeared to result in better control of recurrences of atrial fibrillation in patients with typical atrial flutter (11/13) than in those with atypical atrial flutter (4/8), but the difference was not significant. Ablation for coarse atrial fibrillation was unsuccessful.
CONCLUSIONS—New atrial flutter developing in patients taking class IC antiarrhythmic drugs for recurrent atrial fibrillation has either typical or atypical flutter wave morphology on ECG. The endocardial activation pattern and the acute results of ablation suggest that the flutter circuit was located in the right atrium and that the isthmus was involved in the re-entry mechanism. There appeared to be better long term control of recurrent atrial fibrillation in patients with typical (85%) as compared with atypical atrial flutter (50%). Patients developing coarse atrial fibrillation may not be candidates for this strategy.


Keywords: atrial flutter; antiarrhythmic agents; fibrillation; ablation

Full Text

The Full Text of this article is available as a PDF (502.2 KB).

Figure 1  .

Figure 1  

Open in a new tab

The 12 lead ECG shows: (A) typical atrial flutter with regular and sharp negative atrial deflections in the inferior leads and positive ones in lead V1; (B) atypical atrial flutter with positive and rounded atrial deflections in the inferior leads—the deflections in lead V1 are negative and rounded; and (C) coarse atrial fibrillation with varying intervals and morphology of the atrial deflections.

Figure 2  .

Figure 2  

Open in a new tab

Intra-atrial activation pattern of the same three patients shown in fig 1. (A) Counterclockwise rotation of the atrial flutter (260 ms). (B) Clockwise rotation of the atrial flutter (310 ms). (C) Directionally stable right atrial activation sequence (that is, counterclockwise), but with beat to beat variations in the cycle length. Note that the electrograms from coronary sinus suggest a 1:1 left atrial response in all three patients. Surface ECG leads II, III, AVF, and V1 are shown. The intracardiac electrograms include bipoles of the duodecapolar (Halo) catheter positioned around the tricuspid annulus (H0102-1920) and the bipole located at the coronary sinus ostium (CS).

Figure 3  .

Figure 3  

Open in a new tab

An example of coarse atrial fibrillation. Note that the right atrial endocardial activation shows counterclockwise rotation and cycle length stability. However, the electrograms from the coronary sinus show left atrial fibrillation. H0506-1920 and CS represent intracardiac electrograms from bipoles of Halo and coronary sinus catheter.

graphic file with name hrt-rrm.f1.jpg

Open in a new tab

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Cabrera J. A., Sanchez-Quintana D., Ho S. Y., Medina A., Anderson R. H. The architecture of the atrial musculature between the orifice of the inferior caval vein and the tricuspid valve: the anatomy of the isthmus. J Cardiovasc Electrophysiol. 1998 Nov;9(11):1186–1195. doi: 10.1111/j.1540-8167.1998.tb00091.x. [DOI] [PubMed] [Google Scholar]
  2. Chan D. P., Van Hare G. F., Mackall J. A., Carlson M. D., Waldo A. L. Importance of atrial flutter isthmus in postoperative intra-atrial reentrant tachycardia. Circulation. 2000 Sep 12;102(11):1283–1289. doi: 10.1161/01.cir.102.11.1283. [DOI] [PubMed] [Google Scholar]
  3. Huang D. T., Monahan K. M., Zimetbaum P., Papageorgiou P., Epstein L. M., Josephson M. E. Hybrid pharmacologic and ablative therapy: a novel and effective approach for the management of atrial fibrillation. J Cardiovasc Electrophysiol. 1998 May;9(5):462–469. doi: 10.1111/j.1540-8167.1998.tb01837.x. [DOI] [PubMed] [Google Scholar]
  4. Jaïs P., Haïssaguerre M., Shah D. C., Chouairi S., Gencel L., Hocini M., Clémenty J. A focal source of atrial fibrillation treated by discrete radiofrequency ablation. Circulation. 1997 Feb 4;95(3):572–576. doi: 10.1161/01.cir.95.3.572. [DOI] [PubMed] [Google Scholar]
  5. Konings K. T., Kirchhof C. J., Smeets J. R., Wellens H. J., Penn O. C., Allessie M. A. High-density mapping of electrically induced atrial fibrillation in humans. Circulation. 1994 Apr;89(4):1665–1680. doi: 10.1161/01.cir.89.4.1665. [DOI] [PubMed] [Google Scholar]
  6. Lai L. P., Lin J. L., Lin L. J., Chen W. J., Ho Y. L., Tseng Y. Z., Chen C. H., Lee Y. T., Lien W. P., Huang S. K. New electrocardiographic criteria for the differentiation between counterclockwise and clockwise atrial flutter: correlation with electrophysiological study and radiofrequency catheter ablation. Heart. 1998 Jul;80(1):80–85. doi: 10.1136/hrt.80.1.80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Matsuo K., Kumagai K., Annoura M., Ideishi M., Arakawa K. Mechanism of antiarrhythmic effects of class Ic drugs in paroxysmal atrial fibrillation in man. Cardiology. 1998;89(2):119–123. doi: 10.1159/000006766. [DOI] [PubMed] [Google Scholar]
  8. Nabar A., Rodriguez L. M., Timmermans C., Smeets J. L., Wellens H. J. Isoproterenol to evaluate resumption of conduction after right atrial isthmus ablation in type I atrial flutter. Circulation. 1999 Jun 29;99(25):3286–3291. doi: 10.1161/01.cir.99.25.3286. [DOI] [PubMed] [Google Scholar]
  9. Nabar A., Rodriguez L. M., Timmermans C., Smeets J. L., Wellens H. J. Radiofrequency ablation of "class IC atrial flutter" in patients with resistant atrial fibrillation. Am J Cardiol. 1999 Mar 1;83(5):785-7, A10. doi: 10.1016/s0002-9149(98)00992-8. [DOI] [PubMed] [Google Scholar]
  10. Okumura K., Plumb V. J., Pagé P. L., Waldo A. L. Atrial activation sequence during atrial flutter in the canine pericarditis model and its effects on the polarity of the flutter wave in the electrocardiogram. J Am Coll Cardiol. 1991 Feb;17(2):509–518. doi: 10.1016/s0735-1097(10)80124-x. [DOI] [PubMed] [Google Scholar]
  11. Poty H., Saoudi N., Nair M., Anselme F., Letac B. Radiofrequency catheter ablation of atrial flutter. Further insights into the various types of isthmus block: application to ablation during sinus rhythm. Circulation. 1996 Dec 15;94(12):3204–3213. doi: 10.1161/01.cir.94.12.3204. [DOI] [PubMed] [Google Scholar]
  12. Schumacher B., Jung W., Lewalter T., Vahlhaus C., Wolpert C., Lüderitz B. Radiofrequency ablation of atrial flutter due to administration of class IC antiarrhythmic drugs for atrial fibrillation. Am J Cardiol. 1999 Mar 1;83(5):710–713. doi: 10.1016/s0002-9149(98)00975-8. [DOI] [PubMed] [Google Scholar]
  13. Yamashita T., Inoue H., Nozaki A., Kuo T. T., Usui M., Sugimoto T. Role of anisotropy in determining the selective action of antiarrhythmics in atrial flutter in the dog. Cardiovasc Res. 1992 Mar;26(3):244–249. doi: 10.1093/cvr/26.3.244. [DOI] [PubMed] [Google Scholar]

Articles from Heart are provided here courtesy of BMJ Publishing Group

RESOURCES