Right Atrial Flutter Due to Lower Loop Reentry: Mechanism and Anatomic Substrates
Abstract
BACKGROUND: The mechanisms of an atrial flutter (AFL) that is more rapid and at times more irregular than typical AFL are unknown. METHODS AND RESULTS: Twenty-nine patients with AFL were studied. Atrial electrograms were recorded from a 20-pole catheter placed against the tricuspid annulus (TA), with its distal electrodes lateral to the isthmus between the TA and the eustachian ridge (ER), and from the His bundle and coronary sinus catheters. Atrial extrastimuli were delivered in the TA-ER isthmus during typical AFL. Episodes of a right atrial flutter rhythm that was different from typical AFL were induced in 3 patients and occurred spontaneously in 3 patients. This sustained AFL, designated as lower-loop reentry (LLR), involved the lower right atrium (RA), as manifested by early breakthrough in the lower RA, wave-front collision in the high lateral RA or septum, and conduction through the TA-ER isthmus. Linear ablation resulting in bidirectional conduction block in the TA-ER isthmus terminated spontaneous LLR in 3 patients and rendered LLR noninducible in all patients. The cycle length of LLR was shorter than that of typical AFL (217+/-32 versus 272+/-40 ms, P<0. 01). Alternating LLR and typical AFL in 1 patient resulted in cycle length oscillation. CONCLUSIONS: LLR is a subtype of right atrial flutter and depends on conduction through the TA-ER isthmus.
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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 [125]
The 'lower loop' circuit can be considered a variant of typical atrial flutter in which activation crosses the posterior right atrium and crista terminalis at a lower level than usual, and the ECG often shows a typical flutter pattern.
“the so called 'lower loop' circuit could be considered a variation of typical AFL in which the activation crosses the posterior RA and TC at a lower level than usual, and the ECG tends to show a typical AFL pattern.125”
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 [125]
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Please let every acronym be defined (PLEAD)
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- Authors
- Cheng, J., Cabeen, W. R., & Scheinman, M. M.
- Affiliations
- University of California, San Francisco (US)
- Venue
- Circulation
- Published
- 1999-04-06
- Volume
- 99
- Issue
- 13
- Pages
- 1700-1705
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W1971137991
- Cited by
- 152
- References
- 19
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 2 · 2022: 2 · 2021: 2 · 2020: 1 · 2019: 3 · 2018: 3 · 2017: 2 · 2016: 2 · 2015: 2 · 2014: 1 · 2013: 3 · 2012: 10
- FWCI
- 6.27
- 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
- right atrial flutter, atrial flutter mechanism, tricuspid annulus, bidirectional block, atrial electrograms, atrial flutter ablation
- MeSH terms
- Adult, Aged, Atrial Flutter, Electrocardiography, Electrophysiology, Female, Heart Conduction System, Humans, Male, Middle Aged
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