Physiological basis of atrial

and ventricular
fibrillation and flutter
By Dr Yasir Ishaq
Objectives
• Understand the normal causes of ventricular fibrillation and the
mechanism of fibrillation caused by electrical shock.
• Understand the cause of atrial fibrillation and atrial flutter and the
EKG patterns associated with these conditions.
• Understand the cause of ventricular flutter and the EKG patterns
associated with this condition.
Ventricular Fibrillation
• Some parts of ventricle contract while others relax, thus little
blood flows out of the heart.
• No coordinated contraction of all the ventricular muscle at once,
which is required for a pumping cycle of the heart
• Unconsciousness occurs within 4 to 5 seconds due of lack of
blood flow to the brain, and irretrievable death of tissues begins
throughout the body within a few minutes.
• Caused by electrical shock or cardiac ischemia
PHENOMENON OF RE-ENTRY
—“CIRCUS
MOVEMENTS”
• Normal cardiac impulse does not re excite cardiac muscles as they are
in refractory period
• Impulse dies off, new action potential awaited from sinus node
• Propagation of an impulse in a closed circuit continuously
• Circus movements occur:
• If pathway is long (dilated heart)
• If conduction velocity is decreased (blockade of Purkinje system,
ischemia of muscle, and high K+ levels)
• If refractory period is shortened(epinephrine).
Chain Reaction Mechanism
• Re entrant impulse not moving in a circle rather series of multiple wave fronts
are generated that have the appearance of chain reaction
• 60 cycle stimulus applied–depolarization wave travel in all direction
• leaving all the muscle beneath the electrode in a refractory state.
• Some come out of refractoriness while others still stay
• Continuing 60-cycle stimuli from the electrode cause another impulse travel
only on certain direction.
• Certain impulses travel for short distances until they reach refractory areas
• Impulses pass b/w refractory areas& continue travel in excitable areas
• Establishment of re entry circuits
Chain Reaction Mechanism
• Division of impulses
• Impulse reaching refractory area divide in to 2 around it
• These 2 impulse reach another refractory area and becomes 4
• This way the division of impulses goes on
• Multiple wave fronts are formed by progressive chain reactions
• Many circuitous routes for impulses to travel lengthens the
conductive pathway that sustains the fibrillation
Fibrillation Caused by 60-Cycle Alternating Current (cont’d)
Ventricular Fibrillation (cont’d)
Ventricular Defibrillation
• 1000 volts direct current is applied for a few thousandths of a second.
• All parts of the heart become refractory and remain quiescent for 3-5
seconds until new pacemaker is established.
• If used later than one minute after fibrillation, the heart is too weak
to defibrillate and may have to be hand-pumped
Atrial fibrillation
• Atrial fibrillation most often occurs without ventricular fibrillation.
• Most frequent cause is atrial enlargement due to A-V valve lesions leading
to inadequate emptying ,or from ventricular failure with excess damming
of blood in atria.
• This causes a long conductive pathway, as well as slow conduction which
is favorable for circus movements.
• Efficiency of ventricular pumping is decreased 20 - 30 percent.
• A person can live for years with atrial fibrillation
• Irregular, fast heart rate occurs because of irregular arrival of cardiac
impulse at the A-V node.
Atrial fibrillation (con’t)
• Numerous small depolarization waves spreads in all directions
• Waves are weak and of opposite polarity they usually almost
completely electrically neutralize one another.
• Heart rate becomes 350 to 450 beats/min
• ECG findings
–No P waves but low voltages high frequency waves before QRS-T
complexes
Atrial Fibrillation(con’t)
Atrial fibrillation (con’t)
• Fibrillating atria transmit rapid and irregular impulses
• Interval between successive ventricular contractions varies from a
minimum of about 0.35 second to a maximum of about 0.95 second,
causing a very irregular heartbeat.
• Atria sending impulses at a faster rate so ventricular rate also
becomes faster which is is 125 to 150 beats/min
• Treatment
Cardioversion
Atrial Flutter
• Caused by a circus movement in the atria
• Single large impulse wave travels around atria in one direction
• Atria contracts at 200-350 beats/min
• One side of the atria is contracting while the other side is relaxing, the
small amount of blood is pumped.
• Signals reach AV node too rapidly to be passed into the ventricles as
the refractory periods of the AV node & AV bundle are too long to
pass more than a fraction of the atrial signals
• Therefore, atria may beat 2 or 3 times as rapidly as the ventricle
Ventricular Flutter
• Very rapid and regular ectopic ventricular discharge
• Mechanism: mostly caused by re-entry with a frequency of 300 bpm
• Ventricles depolarize in a circular pattern, which prevents good
function resulting in minimal CO
• Usually short lived due to progression to ventricular fibrillation
• ECG shows: Grossly abnormal intraventricular conduction: QRS
deflexions are very wide and bizarre, one merging with the other
• Difficult to define QRS complex, ST segment and T wave
• This results in appearance of a continuous sine-like waveform
Ventricular Flutter