Circulation, Vol 89, 2117-2125, Copyright © 1994 by American Heart Association
FG Cosio, M Lopez Gil, F Arribas, J Palacios, A Goicolea and A Nunez
BACKGROUND: The mechanisms of common atrial flutter entrainment have not
been directly studied in humans. METHODS AND RESULTS: Endocardial mapping
in six cases of common flutter showed large right atrial (RA) reentry
circuits. Activation was craniocaudal in the anterolateral right atrium and
caudocranial in the septum. The inferior vena cava- tricuspid isthmus
(IVC-TV) closed the circuit. The high right atrium was paced at
progressively shorter cycle lengths (CLs) in all, and the IVC-TV was paced
in three cases. We recorded six to eight simultaneous RA electrograms from
septum and anterior wall. Transient entrainment was recognized from all
sites by capture of all electrograms at two or more paced CLs, with total
or partial preservation of baseline flutter sequence and return to baseline
after pacing. Antidromic circuit penetration was documented in five cases
during high RA pacing and in one with IVC-TV pacing. Short CLs induced
orthodromic conduction delays that resulted in a postpacing pause longer
than basal flutter CL. ECG fusion with high RA pacing correlated poorly
with antidromic septal penetration. This was related to overlap of
orthodromic septal activation with anterior wall activation of the
following cycle. Pacing disorganized flutter into a brief irregular rapid
rhythm in two cases and atrial fibrillation in one case. In two cases,
complete antidromic septal penetration led to sudden flutter interruption,
and in another case it led to circuit inversion. CONCLUSIONS: Direct
recordings confirm orthodromic and antidromic penetration of flutter
circuits by high and low RA pacing. Short CLs modify the circuit.
Disorganization is the most common mode of flutter interruption.
ARTICLES
Mechanisms of entrainment of human common flutter studied with multiple endocardial recordings
Cardiology Service, Hospital Universitario 12 de Octubre, Madrid, Spain.
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