Left Septal Atrial Flutter: Electrophysiology, Anatomy, and Results of Ablation
Abstract
BACKGROUND: We describe the clinical and electrophysiological characteristics of a novel macroreentrant form of left atrial flutter circuit. METHODS AND RESULTS: A total of 11 patients were included in the study. The mean tachycardia cycle length was 278+/-41 ms. Nine of the 11 patients were treated with antiarrhythmic drugs at the time of the study for concomitant atrial fibrillation. With the use of entrainment pacing and either the CARTO Biosense mapping system (9 patients) or conventional mapping (2 patients), the flutter circuit was found to rotate around the left septum primum with a critical isthmus located between the pulmonary veins posteriorly and/or mitral annulus anteriorly and the septum primum. In 5 patients, radiofrequency ablation was performed from the septum primum to the right inferior pulmonary vein (group 1), and in 6 patients, a lesion was made from the septum primum to the mitral annulus (group 2). After a follow-up of 13+/-6 months, 2 patients in group 1 and all patients in group 2 remained in sinus rhythm without recurrence. CONCLUSIONS: Slowing of electric conduction in the left atrial septum due to antiarrhythmic drugs and/or atrial myopathy seems to promote left septal atrial flutter. Radiofrequency ablation of this arrhythmia is usually effective and safe. A line of block between the septum primum and the mitral annulus proved to be effective for cure of tachycardia.
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Atypical atrial flutter/macroreentrant tachycardia of the left atrium is generally supported by abnormal, non-excitable areas of myocardium, sometimes from surgical or ablation scars and sometimes of unknown origin.
“Atypical AFL/MRT of the LA is generally supported by abnormal, non-excitable areas of myocardium, sometimes due to surgical or ablation scars and others of unknown origin.”
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 [162]
These non-excitable areas may form mixed obstacles by attaching to anatomical obstacles such as the mitral valve or pulmonary veins.
“These non-excitable areas may form mixed obstacles by attaching to anatomical obstacles, such as the mitral valve or the pulmonary veins.118,159,162,191,192”
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 [162]
When macroreentrant tachycardia is diagnosed and treated during antiarrhythmic drug therapy, continuation of the drug may be necessary after the circuit is interrupted by ablation.
“When MRT is diagnosed and treated under the effect of AAD, continuation of the AAD may be necessary after interruption of the MRT circuit by ablation.162”
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 [162]
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- Authors
- Marrouche, N. F., Natale, A., Wazni, O. M., Cheng, J., Yang, Y., Pollack, H., Verma, A., Ursell, P., & Scheinman, M. M.
- Affiliations
- Cleveland Clinic (US)
- ORCID
- Venue
- Circulation
- Published
- 2004-05-25
- Volume
- 109
- Issue
- 20
- Pages
- 2440-2447
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2037478585
- Cited by
- 110
- References
- 27
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 2 · 2023: 3 · 2022: 7 · 2021: 8 · 2020: 1 · 2019: 5 · 2017: 4 · 2016: 2 · 2015: 4 · 2014: 6 · 2013: 6 · 2012: 3
- FWCI
- 7.41
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- left atrial flutter, left atrial septum, septum primum, mitral annulus, pulmonary veins, radiofrequency ablation, antiarrhythmic drugs, atrial cardiomyopathy, CARTO mapping, atrial fibrillation
- MeSH terms
- Aged, Atrial Flutter, Female, Follow-Up Studies, Heart Septum, Humans, Male, Middle Aged, Treatment Outcome, Catheter Ablation, Body Surface Potential Mapping
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