ATRIAL

FLUTTER
PRESENTED BY: DR. LADY AIZAHLYN ANGOD (FIRST YEAR RESIDENT)
<<
REACTOR: DR. MARVIN S. GABULE (CARDIOLOGIST)
 SUPRAVENTRICULAR ARRHYTMIAS
q Supraventricular arrhythmias are a diverse
group of atrial arrhythmias.

q Tachyarrhythmias arising above the ventricles.

q Atrial fibrillation and atrial flutter are the most common

of these atrial arrhythmias and the other less common
supraventricular arrhythmias are atrial tachycardias,
atrioventricular reentrant tachycardia and atrioventricular
nodal tachycardia.
SUPRAVENTRICULAR ARRHYTMIAS
TACHYARRHYTHMIAS
 ATRIAL TACHYCARDIA
FOCAL
originating from a small
area of the atrium with
atrial excitation emanating
centrifugally from this focus
MACROREENTRANT
A relatively large reentrant
circuit using conduction
barriers to create the
circuit
 ATRIAL TACHYCARDIA

Atrial flutter is the MACROREENTRANT

most common type of A relatively large reentrant
macroreentrant AT. circuit using conduction
barriers to create the
circuit
 ATRIAL FLUTTER
COMMON/ TYPICAL RIGHT ATRIAL FLUTTER
q Reentrant rhythm in the right atrium that is constrained anteriorly
by the tricuspid annulus and posteriorly by the crista terminalis and
eustachian ridge.

q Flutter can circulate in a counterclockwise direction around the

tricuspid annulus in the frontal plane (counterclockwise flutter) or in
a clockwise direction (clockwise or reverse flutter)

q Cavotricuspid isthmus-dependent atrial flutter

ATRIAL FLUTTER
 ATRIAL FLUTTER
ATYPICAL ATRIAL FLUTTERS
q Macroreentrant ATs that are not dependent on the conduction
through the cavotricuspid isthmus

q Can occur in either atrium and are almost universally associated with
areas of atrial scar.

q Left atrial flutter and perimitral left atrial flutter are commonly seen
after extensive left atrial ablation for atrial fibrillation or atrial surgery.
 ECG
RECOGNITION
ECG RECOGNITION
ISTHMUS DEPENDENT TYPICAL ATRIAL FLUTTER

q The atrial rate during a typical atrial flutter is

usually 250-350 beats/min, but may be
occasionally slower in patients treated with
antiarrhythmic drugs, which can reduce the rate
to about 200 beats/min.

q Atrial Rhythm: regular and stable.

ECG RECOGNITION
ISTHMUS DEPENDENT TYPICAL ATRIAL FLUTTER

q P wave: Recurring, regular, sawtooth flutter waves and evidence of

continual electrical activity (lack of isoelectric interval between flutter
waves), often best visualized in leads II, III, aVF or V1.

q During 2 : 1 or 1 : 1 conduction, transient slowing of the ventricular

response with carotid sinus massage or adenosine is necessary to
visualize the flutter waves.
TYPICAL ATRIAL FLUTTER
COUNTERCLOCKWISE
TYPICAL ATRIAL FLUTTER
REVERSE (CLOCKWISE)
ECG RECOGNITION
ISTHMUS DEPENDENT TYPICAL ATRIAL FLUTTER

q If the AV conduction ratio remains constant, the

ventricular rhythm will be regular.
q The ratio of flutter waves conducted to
ventricular complexes is most often even number:
2: 1, 4:1
ECG RECOGNITION
ATYPICAL FLUTTER

q As mentioned earlier, because the circuits for atypical

flutter (not involving the cavotricuspid isthmus) can be
variable, the electrocardiographic features of these
macroreentrant ATs are highly variable, without
consistent rates or flutter wave contours .

q However, these tachycardia will have flutter rate

similar to that of typical flutter (250-350 bpm)
ECG RECOGNITION
CLINICAL
FEATURES
 CAUSES
q Atrial dilation caused by septal defect
q Pulmonary emboli
q Mitral or tricuspid valve stenosis or regurgitation
q Heart failure
q Previous extensive atrial ablation
q Aging
q Toxic and metabolic conditions that affect the heart,
such as thyrotoxicosis, alcoholism and pericarditis,
q Following surgical repair of congenital heart disease
 SYMPTOMS
q Atrial flutter generally occurs in patients with preexisting
heart disease.

q It may be paroxysmal and transient, persistent (lasting for

days or weeks), or permanent.

q Symptoms of atrial flutter depend on the accompanying

ventricular rate. If the rate is <100 bpm, the patient may be
asymptomatic. Conversely, faster rates often cause
palpitations, dyspnea, or weakness.
MANAGEMENT
 CARDIOVERSION
q Usually the initial treatment of choice because it promptly
and effectively restores sinus rhythm.
q Synchronous Direct Current (DC)à low energy (50J) à if
initial shock results in Atrial Fibrillation à higher energy
level to restore sinus rhythm
q Warranted for hemodynamic instability or severe symptoms.
q May have a high relapse rate, with risk for thromboembolism
immediately after conversion to sinus rhythm.
q Indications for anticoagulation in patients with atrial flutter
are similar to those with AF.
 IBUTILIDE
q Short acting AAD, given intravenously to convert atrial flitter
q Appears to successfully cardiovert approximately 60-90% of
episodes of atrial flutter.
q Prolongs QT interval à torsades de pointes is a potential
complication.
 PROCAINAMIDE or AMIODARONE
q Can be given but generally less effective than ibutilide.
 CATHETER ABLATION
q Preferred approach for stable
patients who do not require
immediate cardioversion.
q Highly effective for typical flutter.
q In this method, an electrode
catheter is inserted into the femoral
vein, passed via the inferior vena
cava to the right atrium, and used to
localize and cauterize (ablate) part of
the reentrant loop to permanently
interrupt the flutter circuit.
 CATHETER ABLATION
q Catheter ablation of typical flutter is
a highly effective cure with long
term success rate of 90-100%
 ANTICOAGULATION
q Indications for anticoagulation is similar to those patients with AF.

q Although risk for thromboembolism may be lower than AF, patients with
Atrial Flutter do have a risk for thromboembolism immediately after
conversion to sinus rhythm.

q Warranted prior to conversion for episodes >48 H duration and chronically

for patients at increased risk for thromboembolic stroke based on
CHAD2SVA2SC scoring system.
ANTICOAGULATION
ANTICOAGULATION
ANTICOAGULATION
 CONTROL OF VENTRICULAR RATE
q Verapamil: initial bolus of 2.5 to 10 mg/kg.
q Diltiazem 0.25mg/kg
q Esmolol
q Digoxin
q IV Amiodarone
 Persistence
q Class IA, IB, IV antiarrhythmics can be tried to restore sinus
rhythm and prevent recurrences.
q Treat underlying disease (thyrotoxicosis)
q Class IA or IC should not be used unless ventricular rate
during atrial flutter has been slowed with calcium antagonist
or beta blocker.
Thank you for
listening J