Electroanatomic mapping of postpacing intervals clarifies the complete active circuit and variants in atrial flutter
Abstract
Background Typical atrial flutter is characterized by cavotricuspid isthmus dependence and activation sequentially around the tricuspid annulus (TA), usually counterclockwise. However, analysis of the upper portion of the annulus by postpacing interval after entrainment sometimes suggests it is outside the circuit. Details on the true active circuit are limited, particularly in the upper portions.Objective The purpose of this study was to define the full active circuit in atrial flutter.Methods In 26 patients with isthmus-dependent atrial flutter, we created detailed electroanatomic maps of postpacing intervals throughout the entire right atrium. Postpacing intervals within 20 ms of the flutter cycle length were defined as within the circuit.Results Creating postpacing interval maps allowed characterization of the full active circuit in all patients, and revealed significant variations despite similar counterclockwise or clockwise patterns with activation mapping. In 8, the active circuit was solely around the TA. In 14, an oblique course between the anterior and posterior borders was found, with the upper circuit off the annulus, posterior to the right atrial appendage base. Of these, 8 coursed anterior to the SVC, 5 behind the SVC and 1 bifurcated the SVC. In 4 others, bifurcation of the upper circuit was seen around the right atrial appendage (n = 3), or around the combined right atrial appendage-superior vena cava (n = 1).Conclusion Despite similar activation around the TA, creating electroanatomic postpacing interval maps distinguishes the active flutter circuit from passively activated myocardium. Significant variability exists in the active circuit, with only a minority around the TA. Most commonly, the circuit courses not around a single barrier but obliquely between anterior and posterior borders.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
If complete block is present, the superior turning point is the atrial roof between SVC and tricuspid ring; otherwise it may be at different levels of the postero-lateral wall across the crista terminalis.
“If complete block is present, the superior turning point is the atrial roof, between the superior vena cava (SVC) and the tricuspid ring, but in other cases the turning point may be at different levels of the postero-lateral wall, across the crista terminalis.125 -127”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [127]
Cites
Feld, G. K., FLECK, R. P., Chen, P., Boyce, K., Bahnson, T. D., Stein, J. B., Calisi, C. M., & Ibarra, M. (1992) · Circulation · doi:10.1161/01.cir.86.4.1233 · Cited by 526 · see citing works
Olgin, J. E., Kalman, J. M., Fitzpatrick, A. P., & Lesh, M. D. (1995) · Circulation · doi:10.1161/01.cir.92.7.1839 · Cited by 500 · see citing works
Role of the Tricuspid Annulus and the Eustachian Valve/Ridge on Atrial Flutter
Nakagawa, H., Lazzara, R., Khastgir, T., Beckman, K. J., McClelland, J. H., Imai, S., Pitha, J. V., Becker, A. E., Arruda, M. S., Gonzalez, M. D., et al. (1996) · Circulation · doi:10.1161/01.cir.94.3.407 · Cited by 363 · see citing works
Kalman, J. M., Olgin, J. E., Saxon, L. A., Fisher, W. G., Lee, R. J., & Lesh, M. D. (1996) · Circulation · doi:10.1161/01.cir.94.3.398 · Cited by 343 · see citing works
Inter-Relationships of Atrial Fibrillation and Atrial Flutter
Waldo, A. L., & Feld, G. K. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2007.08.066 · Cited by 237 · see citing works
Three-dimensional Mapping of the Common Atrial Flutter Circuit in the Right Atrium
Shah, D. C., Jaı̈s, P., Haı̈ssaguerre, M., Chouairi, S., Takahashi, A., Hocini, M., Garrigue, S., & Clémenty, J. (1997) · Circulation · doi:10.1161/01.cir.96.11.3904 · Cited by 205 · see citing works
Atypical Right Atrial Flutter Patterns
Yang, Y., Cheng, J., Bochoeyer, A., Hamdan, M. H., Kowal, R. C., Page, R. L., Lee, R. J., Steiner, P. R., Saxon, L. A., Lesh, M. D., et al. (2001) · Circulation · doi:10.1161/01.cir.103.25.3092 · Cited by 128 · see citing works
Surface electrocardiographic characteristics of right and left atrial flutter
Bochoeyer, A., Yang, Y., Cheng, J., Lee, R. J., Keung, E. C., Marrouche, N. F., Natale, A., & Scheinman, M. M. (2003) · Circulation · doi:10.1161/01.cir.0000079140.35025.1e · Cited by 123 · see citing works
Schumacher, B., Jung, W., Schmidt, H., Fischenbeck, C., Lewalter, T., Hagendorff, A., Omran, H., Wolpert, C., & Lüderitz, B. (1999) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(99)00211-9 · Cited by 104 · see citing works
Waldo, A. L. (1997) · Journal of Cardiovascular Electrophysiology · doi:10.1111/j.1540-8167.1997.tb00798.x · Cited by 97 · see citing works
Coronary thrombolysis in dogs with intravenously administered human pro-urokinase.
Collen, D., Stump, D. C., de Werf, F. V., et al. (1985) · Circulation · doi:10.1161/01.cir.72.2.384 · Cited by 77 · see citing works
TAT, C., Chen, S., Chen, Y., YU, W., HSIEH, M., TSAI, C., CHEN, C., Ding, Y., & Chang, M.-S. (1998) · Journal of Cardiovascular Electrophysiology · doi:10.1111/j.1540-8167.1998.tb00120.x · Cited by 58 · see citing works
Lower Loop Reentry as a Mechanism of Clockwise Right Atrial Flutter
Zhang, S., Younis, G., Hariharan, R., Ho, J. S., Yang, Y., Ip, J. E., Thakur, R. K., Seger, J. J., Scheinman, M. M., & Cheng, J. (2004) · Circulation · doi:10.1161/01.cir.0000124221.84399.48 · Cited by 54 · see citing works
High‐Resolution Mapping Around the Crista Terminalis During Typical Atrial Flutter:
TAI, C., Huang, J., Lee, P.-C., Ding, Y., Chang, M.-S., & Chen, S. (2004) · Journal of Cardiovascular Electrophysiology · doi:10.1046/j.1540-8167.2004.03535.x · Cited by 51 · see citing works
Conduction left-to-right and right-to-left across the crista terminalis
Matsuo, K., Uno, K., Khrestian, C. M., & Waldo, A. L. (2001) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.2001.280.4.h1683 · Cited by 46 · see citing works
CHEN, J., Hoff, P. I., Erga, K. S., Rossvoll, O., & Ohm, O. (2003) · Journal of Cardiovascular Electrophysiology · doi:10.1046/j.1540-8167.2003.03068.x · Cited by 22 · see citing works
Ishida, A., Yoshida, A., Kitamura, H., Kubo, S., Fukuzawa, K., Yamashiro, K., & Yokoyama, M. (2003) · Circulation Journal · doi:10.1253/circj.67.940 · Cited by 22 · see citing works
Entrainment Mapping of Dual‐Loop Macroreentry in Common Atrial Flutter:
Fujiki, A., Nishida, K., Sakabe, M., Sugao, M., Tsuneda, T., Mizumaki, K., & Inoue, H. (2004) · Journal of Cardiovascular Electrophysiology · doi:10.1046/j.1540-8167.2004.03579.x · Cited by 20 · see citing works
Sawa, A., Shimizu, A., Ueyama, T., Yoshiga, Y., Suzuki, S., Sugi, N., Oono, M., Omiya, T., & Matsuzaki, M. (2008) · Circulation Journal · doi:10.1253/circj.72.384 · Cited by 15 · see citing works
Fatemi, M., Mansourati, J., Roşu, R., & Blanc, J. (2004) · Journal of Cardiovascular Electrophysiology · doi:10.1046/j.1540-8167.2004.04278.x · Cited by 14 · see citing works
Maury, P., Duparc, A., HEBRARD, A., Bayomy, M. E., & Delay, M. (2008) · EP Europace · doi:10.1093/europace/eum296 · Cited by 12 · see citing works
Upper Turnover Portion of the Reentry Circuit for Typical and Reverse Typical Atrial Flutter
Fukuzawa, K., Yoshida, A., Kubo, S., Takano, T., Kiuchi, K., Kanda, G., Takami, K., KUMAGAI, H., Torii, S., Takami, M., et al. (2008) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2008.01157.x · Cited by 10 · see citing works
The Atrial Flutter Reentrant Circuit
Hare, G. F. V., & Waldo, A. L. (1996) · Circulation · doi:10.1161/01.cir.94.3.244 · Cited by 9 · see citing works
Electrophysiologic Characteristics of the Sinus Venosa in Patients with Typical Atrial Flutter
TAI, C., Ong, M. G. Y., & Chen, S. (2007) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2007.00932.x · Cited by 7 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Katritsis, D. G., Boriani, G., Cosio, F. G., Hindricks, G., Jaïs, P., Josephson, M. E., Keegan, R., Kim, Y.-H., Knight, B. P., Kuck, K.-H., et al. (2017) · Europace · doi:10.1093/europace/euw301 · Cited by 188 · see citing works
- Authors
- Santucci, P. A., Varma, N., Cytron, J., Akar, J. G., Wilber, D. J., Al Chekakie, M. O., & Brysiewicz, N.
- Affiliations
- Loyola University Chicago (US)
- Cleveland Clinic (US)
- Loyola Medicine (US)
- Corresponding author
- Santucci, Peter A.
- Venue
- Heart Rhythm
- Publisher
- Elsevier BV
- Published
- 2009-11
- Volume
- 6
- Issue
- 11
- Pages
- 1586-1595
- ISSN
- 1547-5271 (ISSN-L)
- OpenAlex
- W2060755407
- Cited by
- 42
- References
- 24
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 2 · 2023: 1 · 2021: 2 · 2020: 1 · 2019: 3 · 2018: 2 · 2017: 2 · 2016: 2 · 2015: 3 · 2014: 1 · 2013: 4 · 2012: 11
- FWCI
- 3.67
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Heart Rhythm (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Keywords
- atrial flutter, electroanatomical mapping, postpacing interval, cavotricuspid isthmus, tricuspid annulus, right atrial appendage, superior vena cava
- MeSH terms
- Adult, Aged, Atrial Flutter, Cardiac Pacing, Artificial, Female, Humans, Male, Middle Aged, Pacemaker, Artificial, Body Surface Potential Mapping
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
