ATRIAL
FLUTTER
PRESENTED BY: DR. LADY AIZAHLYN ANGOD (FIRST YEAR RESIDENT)
<<
REACTOR: DR. MARVIN S. GABULE, FPCP, FPCC, FPVSM
SUPRAVENTRICULAR ARRHYTMIAS
Supraventricular arrhythmias are a diverse
group of atrial arrhythmias.
Tachyarrhythmias arising above the ventricles.
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
MACROREENTRA
FOCAL
NT
originating from a small area A relatively large reentrant
of the atrium with atrial circuit using conduction
excitation emanating barriers to create the circuit
centrifugally from this focus
ATRIAL TACHYCARDIA
MACROREENTRA
Atrial flutter is the most NT
common type of A relatively large reentrant
macroreentrant AT. circuit using conduction
barriers to create the circuit
ATRIAL FLUTTER
COMMON/ TYPICAL RIGHT ATRIAL FLUTTER
Reentrant rhythm in the right atrium that is constrained anteriorly by the
tricuspid annulus and posteriorly by the crista terminalis and eustachian
ridge.
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)
Cavotricuspid isthmus-dependent atrial flutter
ATRIAL FLUTTER
ATRIAL FLUTTER
ATYPICAL ATRIAL FLUTTERS
Macroreentrant ATs that are not dependent on the conduction through the
cavotricuspid isthmus
Can occur in either atrium and are almost universally associated with areas
of atrial scar.
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
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.
Atrial Rhythm: regular and stable.
ECG RECOGNITION
ISTHMUS DEPENDENT TYPICAL ATRIAL FLUTTER
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.
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
If the AV conduction ratio remains constant, the
ventricular rhythm will be regular.
The ratio of flutter waves conducted to ventricular
complexes is most often even number:
2: 1, 4:1
ECG RECOGNITION
ATYPICAL FLUTTER
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 .
However, these tachycardia will have flutter rate similar
to that of typical flutter (250-350 bpm)
ECG RECOGNITION
CLINICAL
FEATURES
CAUSES
Atrial dilation caused by septal defect
Pulmonary emboli
Mitral or tricuspid valve stenosis or regurgitation
Heart failure
Previous extensive atrial ablation
Aging
Toxic and metabolic conditions that affect the heart,
such as thyrotoxicosis, alcoholism and pericarditis,
Following surgical repair of congenital heart disease
SYMPTOMS
Atrial flutter generally occurs in patients with preexisting heart
disease.
It may be paroxysmal and transient, persistent (lasting for days
or weeks), or permanent.
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
Usually the initial treatment of choice because it promptly and
effectively restores sinus rhythm.
Synchronous Direct Current (DC) low energy (50J) if
initial shock results in Atrial Fibrillation higher energy level to
restore sinus rhythm
Warranted for hemodynamic instability or severe symptoms.
May have a high relapse rate, with risk for thromboembolism
immediately after conversion to sinus rhythm.
Indications for anticoagulation in patients with atrial flutter are
similar to those with AF.
IBUTILIDE
Short acting AAD, given intravenously to convert atrial flitter
Appears to successfully cardiovert approximately 60-90% of
episodes of atrial flutter.
Prolongs QT interval torsades de pointes is a potential
complication.
PROCAINAMIDE or AMIODARONE
Can be given but generally less effective than ibutilide.
CATHETER ABLATION
Preferred approach for stable patients
who do not require immediate
cardioversion.
Highly effective for typical flutter.
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
Catheter ablation of typical flutter is a
highly effective cure with long term
success rate of 90-100%
ANTICOAGULATION
Indications for anticoagulation is similar to those patients with AF.
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.
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
CONTROL OF VENTRICULAR RATE
Verapamil: initial bolus of 2.5 to 10 mg/kg.
Diltiazem 0.25mg/kg
Esmolol
Digoxin
IV Amiodarone
Persistence
Class IA, IB, IV antiarrhythmics can be tried to restore sinus
rhythm and prevent recurrences.
Treat underlying disease (thyrotoxicosis)
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
