The endless fascination of right typical atrial flutter: can we predict its occurrence?

The chance for the development of right AFL is strictly related to changes in functional conduction properties of the atrial myocardium which are greatly influenced by fibrotic/scar tissue and increased atrial volume. If these circumstances take place, reduction in conduction velocity can favor a macro-reentry circuit with the wavefront that does not meet its refractory tail and perpetuate the arrhythmia. Therefore, the time required to traverse the entire circuit is related to the circuit’s functional properties. With pacing from the coronary sinus os the right atrial collision time (RACT) of the two wavefronts traveling the circuit in counterclockwise and clockwise direction is calculated. in this prospective study, a cut-off of 115.5 ms of RACT showed a sensitivity and specificity of 92.7% and 93.0% respectively for diagnosis of AFL and an ROC curve indicated an AUC of 0.96 (95% CI: 0.93-1.0, p<0.01). Based on these premises, RACT could be utilized as new marker for the propensity of developing typical AFL.