Coronary sinus pacing initiates counterclockwise atrial flutter while pacing from the low lateral right atrium initiates clockwise atrial flutter

Suzuki, Fumio; Toshida, Nobuo; Nawata, Hiroko; Yamamoto, Nobuto; Hirao, Kazuyuki; Miyasaka, Nobuyuki; Kawara, Tokuhiro; Hiejima, Kazumasa; Harada, Tomoo

doi:10.1016/s0022-0736(98)90020-6

Cited by 10 publications

(7 citation statements)

References 38 publications

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“…Other investigators who have studied clockwise Afl have focused on right atrial activation and obtained little information on CS or left atrial activation pattern. [2][3][4][5] Since Bachmann first described the function of the canine interauricular band (since known as Bachmann's bundle), a number of reports have advanced understanding of interatrial conduction. 6 Two groups have described specialized conduction properties in BB in the dog, reinforcing its importance in interatrial conduction.…”

Section: Discussionmentioning

confidence: 99%

Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter

et al. 2001

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Background-The terms counterclockwise (CC) and clockwise (C) atrial flutter (Afl) are used to describe right atrial activation around the tricuspid valve in the left anterior oblique view. The manner in which the left atrium is activated, as reflected by coronary sinus (CS) recordings, has not been systematically evaluated. Methods and Results-Nine patients with both CC and C Afl underwent electrophysiological study with CS recordings during both rhythms with the use of a decapolar catheter with the tip placed in the distal CS. Patterns of CS activation during each type of Afl as well as during during sinus rhythm were categorized into 1 of 3 patterns: sequential proximal-to-distal, sequential distal-to-proximal, and fused, indicating activation from different directions. In 7 of 9 patients, the pattern of CS activation in CC Afl and C Afl differed, with a proximal-to-distal pattern in CC Afl and a fused pattern in C Afl. In 2 patients, pacing the high right atrial septum near the presumed site of Bachmann's bundle in sinus rhythm showed a similar fused pattern of CS activation. Conclusions-These results demonstrate different patterns of CS activation in CC Afl and C Afl in the majority of patients and are consistent with a model in which the left atrium is activated predominantly over Bachmann's bundle during C Afl and over the CS os in CC Afl. These findings may have implications for maintenance of Afl, interpretation of flutter wave morphology on surface ECG, and left atrial mechanical function in

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Section: Discussionmentioning

confidence: 99%

Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter

et al. 2001

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“…Conversely, reverse typical (CW) AFL is more likely to be induced when pacing from the low lateral right atrium. 17,18 This hypothesis is further supported by direct mapping in animal studies demonstrating that the direction of rotation of the reentrant wavefront during AFL is dependent on the direction of the paced wavefront producing unidirectional block at the time of its induction. 19 In humans, the predominate clinical presentation of type 1 AFL is the typical variety, likely because the trigger(s) for AFL commonly arise from the left atrium in the form of premature atrial contractions or nonsustained atrial fibrillation.…”

Section: Pathophysiologic Mechanisms Of Type 1 Atrial Fluttermentioning

confidence: 87%

“…Induction of atrial flutter typically occurs immediately following the onset of unidirectional CTI isthmus block. 17,18 During electrophysiologic study, a diagnosis of either typical or reverse typical AFL is suggested by observing a counterclockwise or clockwise activation pattern in the right atrium and around the tricuspid valve annulus. For example, as seen in Fig.…”

Section: Electrophysiologic Mapping Of Type 1 Atrial Fluttermentioning

confidence: 99%

Diagnosis and Management of Typical Atrial Flutter

et al. 2009

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“…This may also predispose to the development of unidirectional block in the CTI during rapid atrial pacing, and account for the observation that typical AFL is more likely to be induced when pacing is performed from the coronary sinus ostium, and conversely reverse typical AFL is more likely to be induced when pacing from the low lateral RA [17][18][19]. The predominate clinical presentation is typical AFL, likely because the trigger(s) commonly arise from the left atrium in the form of premature atrial contractions or non-sustained atrial fibrillation [20], which conduct to the RA via the coronary sinus or inter-atrial septum and enter the CTI medially, resulting in clockwise unidirectional block in the CTI with resultant initiation of counterclockwise typical AFL.…”

Section: Pathophysiological Mechanisms Of Typical (And Reverse Typicamentioning

confidence: 99%

“…Induction of AFL is best accomplished by rapid atrial pacing from the coronary sinus ostium, or low lateral RA at CLs between 180-240 ms. Induction of AFL typically occurs following the onset of unidirectional conduction block in the crista terminalis and CTI, either directly or after transient induction of AF [17,18].…”

Section: Standard Catheter Mapping Of Typical (And Reverse Typical) Aflmentioning

confidence: 99%

Mapping of Human Atrial Flutter and Its Variants

2012

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Mapping of human typical atrial flutter (AFL) and its variants can be performed with standard catheter techniques, with special attention to activation patterns and responses to entrainment, allowing one to make an accurate diagnosis that will result in successful ablation of the underlying substrate. Computerized three-dimensional activation mapping is an adjunctive procedure, which while not mandatory may provide significant advantages in some cases, resulting in improved cure rates. The most common forms of AFL in humans include typical (counterclockwise) and reverse typical (clockwise) AFL. The less common variants include upper and lower loop reentrant AFL, partial isthmus dependent AFL, and scar related reentrant AFL. Other forms of AFL, which are rarely seen in humans spontaneously, including intra-isthmus reentry, and atypical left atrial flutter, are more likely to occur after prior ablation procedures. Radio-frequency catheter ablation has become a first line treatment for typical (and reverse typical) AFL, with nearly uniform acute and chronic success and low complication rates. Large-tip or irrigated ablation catheters are recommended for optimal success. Alternate energy sources are under investigation for ablation of AFL, including cryoablation and microwave ablation, with a goal improving procedure times and success rates, and reducing risk of complications.

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Coronary sinus pacing initiates counterclockwise atrial flutter while pacing from the low lateral right atrium initiates clockwise atrial flutter

Cited by 10 publications

References 38 publications

Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter

Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter

Diagnosis and Management of Typical Atrial Flutter

Mapping of Human Atrial Flutter and Its Variants

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