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Revisit of Typical Counterclockwise Atrial Flutter Wave in the ECG: Electroanatomic Studies on the Determinants of the Morphology
Author(s) -
SASAKI KENICHI,
SASAKI SHINGO,
KIMURA MASAOMI,
OWADA SHINGEN,
HORIUCHI DAISUKE,
ITOH TAIHEI,
ISHIDA YUJI,
OKUMURA KEN
Publication year - 2013
Publication title -
pacing and clinical electrophysiology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.686
H-Index - 101
eISSN - 1540-8159
pISSN - 0147-8389
DOI - 10.1111/pace.12129
Subject(s) - medicine , clockwise , flutter , atrial flutter , cardiology , amplitude , p wave , atrial fibrillation , optics , mechanics , physics , aerodynamics
Background Cavotricuspid isthmus‐dependent counterclockwise atrial flutter (typical AFL) is characterized by negative saw‐tooth morphology flutter wave (F‐wave) in the inferior leads, which is classified as type 1 with purely negative F‐wave without positive terminal deflection (PTD), type 2 with small PTD, and type 3 with broad PTD. The determinants of these morphological differences remain to be elucidated. Methods and Results Of 72 patients (58 males, 65 ± 13 years) with typical AFL, 19 were classified as type 1 and 53 as types 2 and 3. We created an electroanatomic map of the right atrium (RA) during AFL and determined which RA site activation corresponded to which F‐wave component by analyzing the activation map. It was revealed that F‐wave component from the nadir to terminal deflection point coincided with the cranio‐caudal activation of the RA free wall (RAFW) in all types. The bipolar voltage map showed that type 1 had the greater extent of low voltage (<0.5 mV) area (LVA) in RAFW (39 ± 24%) than types 2 and 3 (4 ± 3%) (P < 0.0001), explaining the absence of PTD in type 1. In types 2 and 3, F‐wave amplitude determining the PTD magnitude was highly correlated with the longitudinal distance between two points on RAFW corresponding to the nadir and peak of F‐wave (r = 0.73, P < 0.0001). Conclusions Terminal positivity and amplitude of F‐wave in typical AFL are primarily related to the RAFW activity: negatively by the extent of LVA and positively by the longitudinal vector of activation.