Skip to main content
SpringerLink
Log in

Ultra-high resolution mapping of reverse typical atrial flutter: electrophysiological properties of a right atrial posterior wall and interatrial septum activation pattern

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

We aimed to elucidate the right atrial posterior wall (RAPW) and interatrial septum (IAS) conduction pattern during reverse typical atrial flutter (clockwise AFL: CW-AFL).

Methods

This study included 30 patients who underwent catheter ablation of CW-AFL (n = 11) and counter-clockwise AFL (CCW-AFL; n = 19) using an ultra-high resolution mapping system. RAPW transverse conduction block was evaluated by the conduction pattern on propagation maps and double potentials separated by an isoelectric line. The degree of blockade was evaluated by the %blockade, which was calculated by the length of the blocked area divided by the RAPW length. IAS activation patterns were also investigated dependent on the propagation map.

Results

The average %blockade of the RAPW was significantly smaller in patients with CW-AFL than those with CCW-AFL (25 [3–74]% vs. 67 [57–75]%, p < 0.05). CW-AFL patients exhibited 3 different RAPW conduction patterns: (1) a complete blockade pattern (3 patients), (2) moderate (> 25% blockade) blockade pattern (2 patients), and (3) little (< 25% blockade) blockade pattern (6 patients). In contrast, the little blockade pattern was not observed in CCW-AFL patients. Of 11 CW-AFL patients, 4, including all patients with an RAPW complete blockade pattern, had an IAS activation from the wavefront from the anterior tricuspid annulus (TA), and 6 had an IAS activation from the wavefronts from both the anterior TA and RAPW. One patient had IAS activation dominantly from the wavefront from the RAPW.

Conclusions

RAPW transverse conduction blockade during CW-AFL was less frequent than during CCW-AFL, which possibly caused various IAS activation patterns.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

Available upon reasonable request.

References

  1. Saoudi N, Cosio F, Waldo A, Chen S-A, Iesaka Y, Lesh M, et al. Classification of atrial flutter and regular atrial tachycardia according to electrophysiologic mechanism and anatomic bases: a statement from a Joint Expert Group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. J Cardiovasc Electrophysiol. 2001;12(7):852–66.

    Article  CAS  Google Scholar 

  2. Olgin JE, Kalman JM, Fitzpatrick AP, Lesh MD. Role of right atrial endocardial structures as barriers to conduction during human type I atrial flutter. Activation and entrainment mapping guided by intracardiac echocardiography. Circulation. 1995;92(7):1839–48.

    Article  CAS  Google Scholar 

  3. Olgin JE, Kalman JM, Lesh MD. Conduction barriers in human atrial flutter: correlation of electrophysiology and anatomy. J Cardiovasc Electrophysiol. 1996;7(11):1112–26.

    Article  CAS  Google Scholar 

  4. Tai CT, Chen SA, Chen YJ, Yu WC, Hsieh MH, Tsai CF, et al. Conduction properties of the crista terminalis in patients with typical atrial flutter: basis for a line of block in the reentrant circuit. J Cardiovasc Electrophysiol. 1998;9(8):811–9.

    Article  CAS  Google Scholar 

  5. Schumacher B, Jung W, Schmidt H, Fischenbeck C, Lewalter T, Hagendorff A, et al. Transverse conduction capabilities of the crista terminalis in patients with atrial flutter and atrial fibrillation. J Am Coll Cardiol. 1999;34(2):363–73.

    Article  CAS  Google Scholar 

  6. Arenal A, Almendral J, Alday JM, Villacastin J, Ormaetxe JM, Sande JL, et al. Rate-dependent conduction block of the crista terminalis in patients with typical atrial flutter: influence on evaluation of cavotricuspid isthmus conduction block. Circulation. 1999;99(21):2771–8.

    Article  CAS  Google Scholar 

  7. Fukuzawa K, Yoshida A, Kubo S, Takano T, Kiuchi K, Kanda G, et al. Upper turnover portion of the reentry circuit for typical and reverse typical atrial flutter. Pacing Clin Electrophysiol. 2008;31(9):1160–7.

    Article  Google Scholar 

  8. Olgin JE, Kalman JM, Saxon LA, Lee RJ, Lesh MD. Mechanism of initiation of atrial flutter in humans: site of unidirectional block and direction of rotation. J Am Coll Cardiol. 1997;29(2):376–84.

    Article  CAS  Google Scholar 

  9. Sekihara T, Miyazaki S, Nagao M, Kakehashi S, Mukai M, Aoyama D, et al. Ultrahigh resolution electroanatomical mapping of the transverse conduction of the right atrial posterior wall in cases with and without typical atrial flutter. J Cardiovasc Electrophysiol. 2021;32(2):297–304.

    Article  Google Scholar 

  10. Kalman Jonathan M, Olgin Jeffrey E, Saxon Leslie A, Fisher Westby G, Lee Randall J, Lesh MD. Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical atrial flutter. Circulation. 1996;94(3):398–406.

    Article  Google Scholar 

  11. Tai CT, Chen SA, Chiang CE, Lee SH, Ueng KC, Wen ZC, et al. Characterization of low right atrial isthmus as the slow conduction zone and pharmacological target in typical atrial flutter. Circulation. 1997;96(8):2601–11.

    Article  CAS  Google Scholar 

  12. Kalman JM, Olgin JE, Saxon LA, Lee RJ, Scheinman MM, Lesh MD. Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man: use of activation and entrainment mapping and implications for catheter ablation. J Cardiovasc Electrophysiol. 1997;8(2):121–44.

    Article  CAS  Google Scholar 

  13. CosÍO FG, LÓPez-Gil M, Arribas F, GonzÁLez HD. Mechanisms of induction of typical and reversed atrial flutter. J Cardiovasc Electrophysiol. 1998;9(3):281–91.

    Article  Google Scholar 

  14. Ishida A, Yoshida A, Kitamura H, Kubo S, Fukuzawa K, Yamashiro K, et al. Identification of functional block line in atrial flutter using three-dimensional intracardiac echocardiography. Circ J. 2003;67(11):940–4.

    Article  Google Scholar 

  15. Takami M, Yoshida A, Fukuzawa K, Takei A, Kanda G, Takami K, et al. Rate-dependent and site-specific conduction block at the posterior right atrium and drug effects evaluated using a noncontact mapping system in patients with typical atrial flutter. J Cardiovasc Electrophysiol. 2012;23(8):827–34.

    Article  Google Scholar 

  16. Pathik B, Lee G, Sacher F, Jaïs P, Massoullié G, Derval N, et al. New insights into an old arrhythmia: high-resolution mapping demonstrates conduction and substrate variability in right atrial macro–re-entrant tachycardia. JACC. Clin Electrophysiol 2017;3(9):971–86.

    Article  Google Scholar 

  17. Okumura Y, Watanabe I, Ashino S, Kofune M, Ohkubo K, Takagi Y, et al. Electrophysiologic and anatomical characteristics of the right atrial posterior wall in patients with and without atrial flutter: analysis by intracardiac echocardiography. Circ J. 2007;71(5):636–42.

    Article  Google Scholar 

  18. Cheng J, Cabeen William R, Scheinman MM. Right atrial flutter due to lower loop reentry. Circulation. 1999;99(13):1700–5.

    Article  CAS  Google Scholar 

  19. Yang Y, Cheng J, Bochoeyer A, Hamdan MH, Kowal RC, Page R, et al. Atypical right atrial flutter patterns. Circulation. 2001;103(25):3092–8.

    Article  CAS  Google Scholar 

  20. Kawata H, Suyama K, Yokoawa M, Yamagata K, Yokoyama T, Makimoto H, et al. Three dimensional electroanatomical mapping of lower loop reentry in patients with intracardiac operation. J Arrhythm 2011;27(1):38–48.

    Article  Google Scholar 

  21. Fujiki A, Nishida K, Sakabe M, Sugao M, Tsuneda T, Mizumaki K, et al. Entrainment mapping of dual-loop macroreentry in common atrial flutter: new insights into the atrial flutter circuit. J Cardiovasc Electrophysiol. 2004;15(6):679–85.

    Article  Google Scholar 

Download references

Acknowledgements

We greatly appreciate the clinical engineers of our hospital. We would like to thank Mr. John Martin for his help in the preparation of the manuscript.

Author information

Authors and Affiliations

  1. Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan

    Takayuki Sekihara, Shinsuke Miyazaki, Moeko Nagao, Shota Kakehashi, Moe Mukai, Daisetsu Aoyama, Minoru Nodera, Tomoya Eguchi, Kanae Hasegawa, Hiroyasu Uzui & Hiroshi Tada

Authors
  1. Takayuki Sekihara
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shinsuke Miyazaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Moeko Nagao
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shota Kakehashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Moe Mukai
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Daisetsu Aoyama
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Minoru Nodera
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Tomoya Eguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Kanae Hasegawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Hiroyasu Uzui
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Hiroshi Tada
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Takayuki Sekihara.

Ethics declarations

Ethics approval

The study protocol was approved by the hospital’s institutional review board. The study complied with the Declaration of Helsinki.

Informed consent

All patients gave their written informed consent.

Conflict of interest

Dr. Miyazaki belongs to the endowed departments of Medtronic, Boston, Abbott, and Japan Lifeline.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (MP4 2039 KB)

Supplementary file2 (MP4 2850 KB)

Supplementary file3 (MP4 2478 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sekihara, T., Miyazaki, S., Nagao, M. et al. Ultra-high resolution mapping of reverse typical atrial flutter: electrophysiological properties of a right atrial posterior wall and interatrial septum activation pattern. J Interv Card Electrophysiol 63, 333–339 (2022). https://doi.org/10.1007/s10840-021-01003-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-021-01003-0

Keywords

Search

Navigation