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ARTICLE

Body surface mapping of counterclockwise and clockwise typical atrial flutter: a comparative analysis with endocardial activation sequence mapping

Arne SippensGroenewegen, MD^* , Michael D. Lesh, MD, FACC^* , Franz X. Roithinger, MD^* , Willard S. Ellis, PhD^* , Paul R. Steiner, MD^*, Leslie A. Saxon, MD, FACC^*, Randall J. Lee, MD, FACC^* and Melvin M. Scheinman, MD, FACC^*

^* Section of Cardiac Electrophysiology, Department of Medicine, University of California, San Francisco, California, USA
Cardiovascular Research Institute, University of California, San Francisco, California, USA

Manuscript received August 4, 1999; revised manuscript received November 9, 1999, accepted December 29, 1999.

Reprint requests and correspondence: Dr. Arne SippensGroenewegen, Section of Cardiac Electrophysiology, Department of Medicine, University of California at San Francisco, 500 Parnassus Avenue, MU-East 4S, Box 1354, San Francisco, California 94143-1354
sippens{at}ep4.ucsf.edu

OBJECTIVES

This study was directed at developing spatial 62-lead electrocardiogram (ECG) criteria for classification of counterclockwise (CCW) and clockwise (CW) typical atrial flutter (Fl) in patients with and without structural heart disease.

BACKGROUND

Electrocardiographic classification of CCW and CW typical atrial Fl is frequently hampered by inaccurate and inconclusive scalar waveform analysis of the 12-lead ECG.

METHODS

Electrocardiogram signals from 62 torso sites and multisite endocardial recordings were obtained during CCW typical atrial Fl (12 patients), CW typical Fl (3 patients), both forms of typical Fl (4 patients) and CCW typical and atypical atrial Fl (1 patient). All the Fl wave episodes were divided into two or three successive time periods showing stable potential distributions from which integral maps were computed.

RESULTS

The initial, intermediate and terminal CCW Fl wave map patterns coincided with: 1) caudocranial activation of the right atrial septum and proximal-to-distal coronary sinus activation, 2) craniocaudal activation of the right atrial free wall, and 3) activation of the lateral part of the subeustachian isthmus, respectively. The initial, intermediate and terminal CW Fl wave map patterns corresponded with : 1) craniocaudal right atrial septal activation, 2) activation of the subeustachian isthmus and proximal-to-distal coronary sinus activation, and 3) caudocranial right atrial free wall activation, respectively. A reference set of typical CCW and CW mean integral maps of the three successive Fl wave periods was computed after establishing a high degree of quantitative interpatient integral map pattern correspondence irrespective of the presence or absence of organic heart disease.

CONCLUSIONS

The 62-lead ECG of CCW and CW typical atrial Fl in man is characterized by a stereotypical spatial voltage distribution that can be directly related to the underlying activation sequence and is highly specific to the direction of Fl wave rotation. The mean CCW and CW Fl wave integral maps present a unique reference set for improved clinical detection and classification of typical atrial Fl.

Abbreviations and Acronyms   AV = atrioventricular   CCW = counterclockwise   CW = clockwise   ECG = electrocardiogram   Fl = flutter   LAO = left anterior oblique   RAO = right anterior oblique

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