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FOCUS ISSUE: ATRIAL FIBRILLATION: STATE-OF-THE-ART PAPER

Inter-Relationships of Atrial Fibrillation and Atrial Flutter

Mechanisms and Clinical Implications

Albert L. Waldo, MD, FACC^_*,_* and Gregory K. Feld, MD, FACC

^_* Department of Medicine, Division of Cardiovascular Medicine, Case Western Reserve University/University Hospitals of Cleveland Case Medical Center, Cleveland, Ohio
University of California, San Diego, San Diego, California.

Manuscript received July 2, 2007; revised manuscript received August 7, 2007, accepted August 9, 2007.

^_* Reprint requests and correspondence: Dr. Albert L. Waldo, Division of Cardiology, MS LKS 5038, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106-5038. (Email: albert.waldo{at}case.edu).

There is a close interrelationship between atrial fibrillation (AF) and atrial flutter (AFL). Atrial fibrillation of variable duration precedes the onset of AFL in almost all instances; during AF, the functional components needed to complete the AFL re-entrant circuit, principally a line of block (LoB) between the vena cavae, are formed; if this LoB does not form, classical AFL does not develop. In contrast, there seems to be a spectrum of atrial re-entrant circuits (drivers) of short cycle lengths (CLs) (i.e., AFL). When the CL of the AFL re-entrant circuit is so short that it will only activate portions of the atria in a 1:1 manner, the rest of the atria will be activated rapidly but irregularly (i.e., via fibrillatory conduction), resulting in AF. In short, there are probably several mechanisms of AF, 1 of which is due to a very rapid AFL causing fibrillatory conduction. All of these interactions of AF and AFL have important clinical implications.

Abbreviations and Acronyms   AF = atrial fibrillation   AFL = atrial flutter   AVNRT = atrioventricular nodal re-entrant tachycardia   AVRT = atrioventricular re-entrant tachycardia   CL = cycle length   CTI = cavotricuspid isthmus   ECG = electrocardiogram   LA = left atrium   LoB = line of block   RA = right atrium

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