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CLINICAL STUDY: ELECTROPHYSIOLOGY

Variable electrocardiographic characteristics of isthmus-dependent atrial flutter

Paul Milliez, MD, Allison W. Richardson, MD^*,, Ogundu Obioha-Ngwu, MD^*,, Peter J. Zimetbaum, MD, FACC^*,, Panos Papageorgiou, MD, FACC, PhD^*, and Mark E. Josephson, MD, FACC^*,*

^* Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Harvard Medical School, Boston, Massachusetts, USA
Dr. Milliez is currently affiliated with the Lariboisiere University Hospital, Paris, France

Manuscript received August 21, 2001; revised manuscript received June 5, 2002, accepted June 12, 2002.

^* Reprint requests and correspondence: Dr. Mark E. Josephson, Cardiovascular Division, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Boston, Massachusetts 02215, USA
mjoseph2{at}caregroup.harvard.edu

OBJECTIVES: The purpose of this study was to characterize variations in flutter-wave (F-wave) morphology among patients with clockwise isthmus-dependent (CWID) and counterclockwise isthmus-dependent (CCWID) right atrial flutter (AFL) and to attempt to correlate F-wave morphology with echocardiographic data and clinical patient characteristics.

BACKGROUND: Variations in F-wave morphology on surface electrocardiogram (ECG) during CCWID and CWID flutter have been reported but never systematically characterized.

METHODS: Over a four-year period, 139 patients with AFL on ECG underwent electrophysiologic study and echocardiography at our institution. Electrocardiographic data, intracardiac recordings, echocardiographic data, and patient characteristics were reviewed retrospectively.

RESULTS: Of 156 AFLs evaluated, 130 were CCWID, 26 were CWID. Three types of CCWID flutter were observed: type 1 had purely negative F-waves inferiorly, types 2 and 3 had F-waves inferiorly with small (type 2) or broad (type 3) positive terminal deflections; CCWID flutter types 2 and 3 were associated with higher incidence of left atrial (LA) enlargement, heart disease, and atrial fibrillation (Afib) than type 1. Two types of CWID flutter were observed: type 1 had notched positive F-waves with a distinct isoelectric segment inferiorly. Type 2 had broader F-waves inferiorly with positive and negative components and a short isoelectric segment.

CONCLUSIONS: Variable ECG patterns for CCWID and CWID AFL exist. A positive component of the F-wave in the inferior leads during CCWID flutter is associated with an increased likelihood of heart disease, Afib, and LA enlargement.

Abbreviations and Acronyms   Afib   atrial fibrillation   AFL   atrial flutter   ALRA   anterolateral right atrium   CCWID   counterclockwise isthmus-dependent   CL   cycle length   CS   coronary sinus   CWID   clockwise isthmus-dependent   ECG   electrocardiogram/electrocardiographic   EPS   electrophysiologic study   F-wave   flutter wave   LA   left atrial   left atrium   RA   right atrial   right atrium

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