“Terapia medica o ablazione per le più comuni aritmie. Bruciare o ingoiare pillole amare?” Pietra Ligure 12 Aprile 2008

Fisiopatologia e clinica del Flutter Atriale Dott.Paolo Sartori A.O. Universitaria San Martino Genova

Definizione del Flutter Atriale Aritmia sopraventricolare da rientro il cui circuito è nella maggior parte dei casi intorno alla valvola tricuspide che lo delimita anteriormente; posteriormente da barriere anatomiche . Il ciclo di tale aritmia, in assenza di farmaci antiaritmici, varia dai 220-280 msec. Il rapporto A/V è > = a 1

Barriere anatomiche delimitanti il circuito Crista Terminalis SVC TV CS Eustachian ridge Point out right atrial structures relevant to atrial flutter ablation: 1. SVC 2. IVC 3. Thebesian valve (sinus venarium minimarum) of coronary sinus 4. Septal (medial) leaflet of the tricuspid valve and the annulus of tricuspid valve 5. Eustachian ridge (crescent shaped valve) Atrial portion of the membranous septum- also the inter-atrial septum: posterior-medial aspect of the right atrium 6. Crista terminalis- posterior barrier of reentrant circuit in atrial flutter. Poor transverse conduction properties of CT may be a requisite substrate for clinical occurrence of atrial flutter. a. Anterior free wall- pectinate muscle. Highly trabeculated. ( runs anterior to the IVC) b. Posterior wall- sinus venarium Also, the Fossa Ovalis, true atrial septum IVC

Barriere anatomiche delimitanti il circuito LAO RAO

Classificazione del Flutter atriale Type II ? Typical Reverse flutter Type IC Atypical Isthmus dependent Macro reentry Antidromic Type I Non Isthmus dependent 1.The proliferation of descriptive terminology has resulted in some confusion and the need to better clarify and more accurately define atrial flutter and related arrhythmia's. Clockwise Proliferation of descriptive terminology confusing in the literature; therefore a simple definition was required to avoid confusion Orthodromic Usual Counter clockwise Type I Classic Common Orthodromic CCW isthmus dependent Typical CCW Type A Type II Atypical Uncommon Rare Antidromic Clockwise Reverse typical CW Lesion flutter Left atrial flutter

Criterio di classificazione Substrato anatomico Attivazione Caratteristiche dell’entrainment NASPE position paper defined atrial flutter based on compilation of current knowledge. Atrial flutter is classified as an macro reentrant tachycardia Reentry is around a large central obstacle Central obstacle may be fixed, functional, or a combination of the two Defined relative to atrial anatomy In this presentation we will focus on typical and reverse typical AFL Both are Isthmus dependent Both are “using” the same “circuit”, however in opposite directions Both are amenable to anatomic ablation technique Others: (not in the scope of this presentation) Lesion Macro reentrant tachycardia Right free-wall macro-reentry without atriotomy Left atrial macro- reentry tachycardia Type 1-C antiarrhythmic (drug) mediated tachycardia 4. Saoudi, N. et. al. “Classification of Atrial Flutter and Regular Tachycardia According to Electrophysiologic Mechanism and Anatomic Bases: A Statement from a Joint Expert Group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Electrophysiology.” JCE, volume 12, No. 7, pp. 852-866. July 2001. 2001 NASPE Proposed AFL Classification4

Classificazione

Flutter Atriale Tipico Circuito di rientro anatomico Flutter atriale comune Flutter atriale non comune

Flutter Atriale Tipico comune +DI +V1 +DII,DIII,aVF

Flutter Atriale Tipico non comune +DI +V1 +II,III,aVF

ECG FLUTTER ATRIALE TIPICO COMUNE Sawtooth pattern The incidence of A-V block makes the P wave sawtooth pattern easier to see. Isthmus dependent Typical AFL (CCW) Atrial rhythm: regular and very stable (240-340 bpm) P wave: Characteristic saw tooth pattern with a predominantly negative deflection in, II and III, and/or aVf (inferior axis) and positive in V1 (but may be negative or biphasic). Leads I and aVL show low-voltage deflections 3:1 A-V Block

ECG FLUTTER ATRIALE TIPICO NON COMUNE

Posizione dei cateteri

Proiezioni radiologiche RAO

Proiezioni radiologiche LAO

Segnali endocavitari Flutter atriale comune Flutter atriale non comune DD1-2 DD1-2 DD3-4 DD3-4 DD5-6 DD5-6 DD7-8 DD7-8 DD9-10 DD9-10 DD11-12 DD11-12 DD13-14 DD13-14 DD15-16 DD15-16 DD17-18 DD17-18 DD19-20 DD19-20 Flutter atriale comune Flutter atriale non comune

MAPPAGGIO DURANTE FLUTTER ATRIALE

Attivazione del FL. A comune Activation sequence typical counterclockwise right atrial isthmus dependent atrial flutter

MAPPAGGIO DURANTE RITMO SINUSALE HRA HRA LRA LRA

Entrainment

SINTOMATOLOGIA A seconda del rapporto A/V Asintomatico  Segni obiettivi di scompenso Cardiopalmo Dispnea Lipotimie Sincope Angina

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