AF clockwise or anticlockwise

8/7/2019 AF clockwise or anticlockwise

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BY

Dr. Rania samir

Lecturer o Car io ogy

Ain Shams University

Atrial flutter represents the most important &most common atrial tachyarrhythmia after AF

The re-entry circuits often occupy large areas -

reentrant

The overall incidence of atrial flutter in a

recent population study was 0.88%,

0.05% in patients < 50 years old5.87% among individuals > 80 years of age.

(Granada et al, 2000)


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Many different forms of atrial flutter exist & since it

,

used to characterize atrial flutter, particularly

recently, to the point that atrial flutter terminology

has become quite confusing

.

First simple classification based on ECG patterns, in1970

-T ical atrial flutter Counter-clockwise

- Atypical atrial flutter (Clockwise)


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Based on advanced EP mapping techniques which identified different EP-mechanisms of atrial flutter

-atrial flutter

atrial flutter

Atypical atrial flutter

The re-entry circuit isconfined to RA & involvesthe CTI as a critical zone of

slow conduction

any fixedmacroreentrant atrial

circuit that doesntinvolve the CTI

Type II atrial flutter

heterogenous flutterwave morphology

May be due to rapidreentry with

CCW A. flutter

(commonest 90%)

CW A. flutter (less

commom 10%)

Lower loop re-entrry

Lesion macroreentrantatrial tachycardia (mostcommon)

upper loop reentry

LA flutter (rare)

variable fib.

Conduction

ACC/AHA/ESC Guidelines 2003

isthmus dependent atrial

due to a macroreentrant

circuit rotating in either a

counterclockwise

(common) or clockwise

(uncommon) direction inIAS

CT

e r g a r um, w an

area of relatively slowconduction in the low

posterior right atrium

IVCER

CS

TA


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Atrial flutter is most often a nuisance arrhythmia & itsclinical si nificance lies lar el in its fre uentassociation with AF or rapid ventricular responsewhich is principally responsible for many of theassociated symptoms So, maintenance of SR afterCV is mandatory in cases of recurrent A.flutter

,offered a limited ability to maintain SR withoutoccasional to frequent recurrences of A.flutter, evenwhen multiple agents are used.

Reported long term success rates ranging from 50% forclass I to 73% for class III (oral dofetilide)

Also, long-term rate control alone usually requires largedoses of AV nodal blocking agents

Singh et al, Circulation 2000


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Approaches to endocardial mapping of A flutter

include standard multielectrode catheters, Expanding

e ec ro e arrays or mapp ng ec n ques u s

Standard multielectrode catheter-based mapping still

remains the main tool for the study of A flutter

The recent advances in this therapeuticapproac were assoc a e w g success

rates, low recurrence rates and minimalcomplications.

IAS

LAOLAO

IAS

Isthm

IsthmIVC


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Large randomized trials, RF- ablation creating linear lesionsacross the critical zone of slow conduction (CTI) till achievemento as an en po n o a a on

High success rates 90-100%

Low recurrence rate 6-9%

over a period of 9-17 mo

(Tai et al., 1998) (Wu et al.,2002)

RAOLAO

Ain Shams University EP lab


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During PCS pacing

Before ablation After ablation

Complete CW block


LRA pacing

Before ablation After ablation

Complete CCW block



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Variation in the isthmus widthIsthmus width 17-54 mm

Isthmus width > 39 mm or Cath-IVC an le 5mm deep pouch


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Comparing the published success rates of AADs inmaintaining SR to significantly high long term success rates

of RF-ablation Favors RF ablation as an acceptabletherapeutic approach of A . flutter

ACC/AHA/ESC guidelines,2003

Although the success rates of RF-ablationusing conventional & 3D mapping techniquesare similar

Shorter fluoroscopy time (3.915 vs 22 6.3 min)(Kottkamp et al, 2000)

Precise identification of discrete gaps withinnon-contiguous lesion lines the ability to

sites Fast & reliable identification of WSDP along

the ablation line


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TCL 240 ms


CS pacing before ablationCS pacing after ablationshowing CW isthmus block



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Before ablationAfter ablation



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Isthmus ablation in patients with atrial flutter hasproved positive impact on QOL.

a e er a a on s cura ve n many pa en sobviating the need for life-long AADs,and may bemore cost effective on the long term than AADtherapy.

Substantial fluoroscopy exposure, whichis necessaryor conven ona s mus a a on, s s gn can y

reduced with 3D mappingfor isthmus ablation whichhave an impact on the long-term safety of this invasivetreatment strategy.

AF clockwise or anticlockwise

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