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CLINICAL RESEARCH: HEART RHYTHM DISORDER

A New Electrocardiographic Algorithm to Differentiate Upper Loop Re-Entry From Reverse Typical Atrial Flutter

Yoga Yuniadi, MD^_*, Ching-Tai Tai, MD^,_*, Kun-Tai Lee, MD, Bien-Hsien Huang, MD, Yenn-Jiang Lin, MD, Satoshi Higa, MD, Tu-Ying Liu, MD, Jin-Long Huang, MD, Pi-Chang Lee, MD and Shih-Ann Chen, MD

^_* Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, and National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
Division of Cardiology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan

Manuscript received November 10, 2004; revised manuscript received April 12, 2005, accepted April 14, 2005.

^_* Reprint requests and correspondence: Dr. Ching-Tai Tai, Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan (Email: ct.tai{at}msa.hinet.net).

OBJECTIVES: This study was performed to differentiate upper loop re-entry (ULR) from reverse typical atrial flutter (AFL).

BACKGROUND: Right atrial ULR and reverse typical AFL have different mechanisms and ablation strategies, but similar electrocardiographic characteristics.

METHODS: This study included 26 patients with reverse typical AFL and 20 patients with ULR. The noncontact mapping system (EnSite-3000, Endocardial Solutions, St. Paul, Minnesota) was used to confirm diagnosis and guide successful radiofrequency ablation. Flutter wave polarity and amplitude in the 12-lead surface electrocardiogram were determined by two independent electrophysiologists.

RESULTS: The flutter wave polarity in leads I and aVL was significantly different between the reverse typical AFL and ULR groups (p 0.001). Voltage measurement revealed significant differences between reverse typical AFL and ULR in leads I, II, aVR, aVF, V₁, and V₂ (p < 0.001). A new diagnostic algorithm based on negative or isoelectric/flat flutter wave polarity and amplitude 0.07 mV in lead I was useful for diagnosis of ULR, with an accuracy of 90% to 97%, a sensitivity of 82% to 100%, and a specificity of 95%.

CONCLUSIONS: Polarity and voltage measurement of flutter wave in lead I can differentiate reverse typical AFL from ULR.

Abbreviations and Acronyms   AFL = atrial flutter   AV = atrioventricular   CTI = cavotricuspid isthmus   ECG = electrocardiogram/electrocardiographic   MEA = multi-electrode array   ROC = receiver-operating characteristic   SVC = superior vena cava   ULR = upper loop re-entry

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