(Circulation. 1999;99:1700-1705.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Right Atrial Flutter Due to Lower Loop Reentry
Mechanism and Anatomic Substrates
From the Section of Cardiac Electrophysiology, University of California San Francisco, and the Pacific Heart Institute, Santa Monica, Calif (W.R.C.). Dr Cheng is now at SUNY Health Science Center at Syracuse, Syracuse, NY.
Correspondence to Melvin M. Scheinman, MD, Cardiac Electrophysiology, University of California San Francisco, 500 Parnassus Ave, MU East 4S Box 1354, San Francisco, CA 94143-1354. E-mail scheinman{at}ep4.ucsf.edu
Background—The mechanisms of an atrial flutter (AFL) that is more rapid and at times more irregular than typical AFL are unknown.
Methods and Results—Twenty-nine patients with AFL were studied. Atrial electrograms were recorded from a 20-pole catheter placed against the tricuspid annulus (TA), with its distal electrodes lateral to the isthmus between the TA and the eustachian ridge (ER), and from the His bundle and coronary sinus catheters. Atrial extrastimuli were delivered in the TA-ER isthmus during typical AFL. Episodes of a right atrial flutter rhythm that was different from typical AFL were induced in 3 patients and occurred spontaneously in 3 patients. This sustained AFL, designated as lower-loop reentry (LLR), involved the lower right atrium (RA), as manifested by early breakthrough in the lower RA, wave-front collision in the high lateral RA or septum, and conduction through the TA-ER isthmus. Linear ablation resulting in bidirectional conduction block in the TA-ER isthmus terminated spontaneous LLR in 3 patients and rendered LLR noninducible in all patients. The cycle length of LLR was shorter than that of typical AFL (217±32 versus 272±40 ms, P<0.01). Alternating LLR and typical AFL in 1 patient resulted in cycle length oscillation.
Conclusions—LLR is a subtype of right atrial flutter and depends on conduction through the TA-ER isthmus.
Key Words: atrial flutter • ablation • electrical stimulation
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