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Additional head on ablation flutter line12/30/2023 ![]() These structures provide anatomical or functional barriers of conduction, which allow for depolarization through a protected zone of slow conduction and propagation of the arrhythmia. The CTI is bounded anteriorly by the tricuspid annulus and posteriorly by the inferior vena cava Eustachian ridge ( Figure 2.1). For this chapter, we refer to both typical and reverse forms collectively as AFL.Īn understanding of CTI anatomy and physiology is fundamental for ablation of AFL. “Reverse typical flutter” is defined as using the same anatomic circuit but propagating in the clockwise direction. 3 CTI-dependent, right atrial (RA) macroreentrant tachycardia in the counterclockwise direction of propagation around the tricuspid annulus is defined as “typical” AFL. 2 In 2001, a consensus document recommended standardized terminology for AFL. Specifically, these terms have been used to characterize the flutter circuits based on direction of conduction around the tricuspid annulus ( counterclockwise or clockwise), whether it is right- or left-sided, whether its conduction is dependent upon the CTI ( isthmus-dependent and non-isthmus dependent), or a combination of these factors ( typical, reverse typical, atypical, type 1, type 2). Since its discovery in 1920 by Sir Thomas Lewis, 1 numerous terms have been used to describe AFL. For these reasons, catheter ablation of typical AFL is one of the most common procedures performed in invasive cardiac EP. Ablation can also be performed without advanced EP laboratory equipment such as electroanatomic mapping, intracardiac ultrasound, or non-contact mapping catheters, although these tools can be useful in complex cases or when the diagnosis is difficult to establish. Catheter ablation of typical flutter is generally straightforward and success rates are high, while complication rates are quite low. Even when AFL presents in the absence of AF or structural heart disease, it may have serious adverse effects, including stroke and systemic embolism, extreme tachycardia, myocardial ischemia, pulmonary venous congestion, tachycardia-induced cardiomyopathy, and heart failure. AFL may be an isolated arrhythmia or occur in conjunction with atrial fibrillation (AF). AFL is common and relatively refractory to medical therapies for rate and rhythm control. Typical atrial flutter (AFL) is a right atrial macroreentrant arrhythmia dependent upon conduction across the cavotricuspid isthmus (CTI). Therefore, optimally, both methods should be used concomitantly.How to Ablate Typical and Reverse Atrial Flutter However, when combined with the activation mapping technique, it provided additional information regarding isthmus conduction properties in some cases. On-site, clear-cut, widely spaced double atrial potentials and activation mapping suggesting CBIB were concomitantly observed in only 47 patients (54%), and ambiguous/atypical double potentials were recorded in 31 patients (39%).Īlthough feasible, the on-site atrial potential analysis seemed to be inferior to the classic activation mapping technique, mainly because of the ambiguity of electrogram interpretation along the ablation line. In successful patients, the mean radiofrequency delivery duration was longer in group II (845+/-776 versus 534+/-363 s P:=0.03). The CBIB criterion was retrospectively searched using the alternative technique at the end of the procedure. Criteria for CBIB using on-site atrial potential analysis was the recording of parallel, widely spaced double atrial potentials along the ablation line. In 76 consecutive patients (mean age, 63.4+/-10.5 years), typical atrial flutter ablation was performed using either the activation mapping technique (group I) or on-site atrial potential analysis (group II). The study was designed to compare these 2 techniques prospectively regarding the diagnosis of CBIB. Mapping only the ablation line ("on-site" atrial potential analysis) was recently reported as a means of CBIB identification. Complete bidirectional isthmus conduction block (CBIB) was initially assessed by sequential detailed activation mapping at both sides of the ablation line during proximal coronary sinus and anteroinferior right atrium pacing.
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