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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

View larger version (17K): [in a new window]   Figure 1 This figure shows schemas of variable flutter wave morphologies on 12-lead electrocardiograms. The first two waves are monophasic positive (F+) and negative (F–) flutter waves. The third through sixth waves are biphasic flutter waves, consisting of dominant negative with small terminal positive (F–/f+), dominant positive with small terminal negative (F+/f–), small initial negative with dominant terminal positive (f–/F+), and the equal amplitude of negative and positive waves (Isoelectric). Flat polarity is amplitude <0.01 mV and more than –0.01 mV.

View larger version (43K): [in a new window]   Figure 2 During reverse typical atrial flutter (AFL), the flutter wave in lead I demonstrates prominent (>0.07 mV) positive polarity (A). During upper loop re-entry (ULR), lead I demonstrates either negative flat (B) or small (0.07 mV) positive (C) polarity. Note the similarities of flutter waves in inferior leads between reverse typical and ULR AFL.

View larger version (23K): [in a new window]   Figure 3 This dot diagram shows voltage amplitude distribution of flutter wave in lead I. Receiver-operating characteristic analysis found that a cutoff point of >0.07 mV has a sensitivity (Sens) 89.3% and a specificity (Spec) of 100% in differentiating between reverse typical atrial flutter (group 1) and upper loop re-entry (group 0). AFL = atrial flutter.

View larger version (18K): [in a new window]   Figure 4 The new diagnostic algorithm to differentiate between upper loop re-entry (ULR) and reverse typical atrial flutter (RTAFL). Flat polarity is defined as polarity of <0.01 mV, but more than –0.01 mV. Isoelectric is defined as biphasic polarity in which negative and positive deflection has equal amplitude.