Global Right Atrial Mapping of Human Atrial Flutter: The Presence of Posteromedial (Sinus Venosa Region) Functional Block and Double Potentials: A Study in Biplane Fluoroscopy and Intracardiac Echocardiography
Abstract
BACKGROUND: Previous studies of atrial flutter have found linear block at the crista terminalis; this was thought to predispose the patient to the arrhythmia. More recent observations, however, have demonstrated crista conduction. We sought to characterize the posterior boundary of atrial flutter. METHODS AND RESULTS: Patients with counterclockwise flutter (n=20), clockwise flutter (n=3), or both (n=5) were studied using two 20-pole catheters. Biplane fluoroscopy determined catheter positions. During counterclockwise flutter, craniocaudal activation occurred along the entire lateral and posterior right atrial walls. Septal activation proceeded caudocranially. In all patients, a line of block was seen in the posteromedial (sinus venosa) right atrium; this was manifested by the presence of double potentials where the upward and downward activations collided. Anatomic location was confirmed by intracardiac echocardiography in 9 patients. In patients with clockwise flutter, the line of block and double potentials were seen in the same location during counterclockwise flutter, but the activation sequence around the line of block was reversed. Pacing near the site of double potentials during sinus rhythm excluded a fixed line of block, and premature atrial complexes demonstrated functional block with manifest double potentials. In 2 patients, posterior ectopy organized to subsequently initiate isthmus-dependent atrial flutter. CONCLUSIONS: (1) A functional line of block is seen at the posteromedial (sinus venosa region) right atrium during counterclockwise and clockwise atrial flutter. (2) All lateral wall right atrial activation can be uniform during flutter, without linear block or double potentials in the region of the crista terminalis. (3) Activation at the site of posteromedial right atrial functional block can organize to subsequently initiate isthmus-dependent atrial flutter.
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The reentry mechanism of typical AFL is supported by a line of conduction block in the posterior RA extending from IVC toward SVC, most often related to anisotropic conduction at the crista terminalis, though other posterior RA structures may play a role.
“The reentry mechanism is supported by a line of conduction block in the posterior RA, extending from the IVC toward the SVC, most often related to anisotropic conduction at the crista terminalis, 123 although other structures of the posterior RA may also play a role.124”
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 [124]
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- Authors
- Friedman, P. A., Luria, D., Fenton, A. M., Munger, T. M., Jahangir, A., Shen, W. K., Rea, R. F., Stanton, M. S., Hammill, S. C., & Packer, D. L.
- Affiliations
- Mayo Clinic (US)
- Venue
- Circulation
- Published
- 2000-04-04
- Volume
- 101
- Issue
- 13
- Pages
- 1568-1577
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2004633588
- Cited by
- 117
- References
- 16
- Citations by year
- 2025: 1 · 2024: 1 · 2022: 4 · 2021: 3 · 2020: 2 · 2019: 2 · 2017: 3 · 2016: 2 · 2015: 2 · 2013: 3 · 2012: 2
- FWCI
- 8.16
- 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 › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Keywords
- atrial flutter, function blocks, double potentials, crista terminalis, isthmus-dependent atrial flutter, atrial activation sequence, intracardiac echocardiography
- MeSH terms
- Adult, Aged, Aged, 80 and over, Atrial Flutter, Echocardiography, Electrocardiography, Electrophysiology, Female, Fluoroscopy, Heart Block, Humans, Image Processing, Computer-Assisted, Male, Middle Aged, Atrial Function, Right
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