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(Circulation. 1996;94:244-246.)
© 1996 American Heart Association, Inc.

Articles

The Atrial Flutter Reentrant Circuit

Additional Pieces of the Puzzle

George F. Van Hare, MD; Albert L. Waldo, MD

the Divisions of Cardiology, Departments of Medicine and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Correspondence to Albert L. Waldo, MD, Division of Cardiology, University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH 44106.

Key Words: atrial flutter • reentry • electrophysiology • arrhythmia • catheter ablation • Editorials

	Introduction

 
For a time, there was a substantial school of thought that held that atrial flutter was due to a single focus firing rapidly.¹ It has more recently been established that atrial flutter is due to reentry.¹ Over the years, and largely on the basis of animal studies, the nature of the atrial flutter reentrant circuit has been thought or demonstrated to include reentry around anatomic obstacles such as the great veins or the pulmonary veins, reentry around atrial lesions, and reentry around functional obstacles.² Reentry around the tricuspid annulus was demonstrated in the presence of critical right atrial lesions,³ and many years ago, Sir Thomas Lewis could only explain a limited sequential site atrial flutter map in a canine model by postulating reentry around the mitral annulus.⁴ However, it is now accepted that classic (type I) atrial flutter in patients is due to macroreentry involving the right atrium.¹ Initial activation mapping studies of the typical form of atrial flutter in patients showed a "counterclockwise" reentrant activation in the right atrium,^{5 6 7} but the elements of the right atrium that supported reentry and were critical to the maintenance of the atrial flutter reentrant circuit were not yet appreciated.

From studies using concealed entrainment techniques⁸ as well as techniques for precise placement of ablative lesions, it is now well established that one critical element of the atrial flutter reentrant circuit is the isthmus between the inferior vena cava and the tricuspid valve annulus.⁹ In this issue of Circulation, two carefully performed studies . . . [Full Text of this Article]

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