Health care workers

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Atrial Flutter

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Flutter
 After atrial fibrillation, atrial flutter is the most
significant of the atrial tachyarrhythmias.
 Flutter waves
 Risk of embolization
 Co-morbidities common
 A-V block common
 Use NavX or Array

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Flutter
 Type I and Type II
 Type I (Typical)
 240-340
 counter-clockwise (Common) & clockwise
 Isthmus-dependent atrial flutter
 Typically entrainable.

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Flutter
 Type II (Atypical)
 rate greater than 340
 Atypical aflutter, not using the isthmus
 May be crossing the crista terminalis, using slow conduction of
incisional scar, but may result from an intraatrial reentrant circuit
operating at a faster rate
Isthmus conduction may be present
Figure of eight pattern

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Mechanism
 Involves a re-entrant circuit that encircles the tricuspid annulus of the right atrium, with a
depolarizing stimulus traveling up the atrial septum, experiencing epicardial break-through
superiorly, and traveling back down the atrial free wall and repeating by traveling through a
slowly conducting isthmus allowing the rest of the chamber to repolarize and repeat
depolarization of the septum.

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Anatomy

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RAO & LAO

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Typical Flutter
November 20, 2023
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Catheters and Considerations
Diagnostic
• 8 French, 63cm, Fast Cath, Guiding introducer from Swartz
SR series
• SRO, SAFL, RAMP
Diagnostic – 4-5-6 French Decapolar,
• Fixed Curve: JSN (Josephson), DAO (Damato)
–2-5-2, 2-2-2 spacing
–Supreme, IBI Inquiry, Response (economy and signal
quality)
• Steerable Livewire Decapolar, 7FR Livewire Duo-Decapolar
(selective spacing), Duo-Deca BDB
–Match connector cables

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Catheter Positions

11. Catheter Positions

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Fluoroscopic Positions
CS
DuoDec
RV
HIS
RV
HIS
CS
DuoDec LAO
RAO

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Intracardiac Electrogram Recognition – CCW
Mapping
Sequential activation around the right atrium

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Intracardiac Electrogram Recognition – CW
Mapping
Sequential activation around the right atrium

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RF Ablation
November 20, 2023
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Double Potentials during RF
November 20, 2023
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Successful Ablation - End
November 20, 2023
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Bi-directional Block Check
CS Pacing Post Ablation, with Isthmus Block

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Bi-directional Block Check
LRA Pacing Post Ablation, with Isthmus Block

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Conclusions
 Study the EKG
 Confirm diagnosis with pacing for entrainment and block
 Select the right tools for access and catheter stability
 Pace to confirm bi-directional block

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Knowledge Check
November 20, 2023
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Diagnosis?

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Diagnosis?
November 20, 2023
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Site of Ablation Cath?
November 20, 2023
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