Contemporary Management of Atrial Flutter

A 60-year-old dentist presents to the emergency room with palpitations for 3 hours.The ECG shows atrial flutter (AFl) with atrioventricular (AV) conduction varying from 2:1 to 4:1.He has known hypertension for which he takes 10 mg of enalapril daily.In the last 2 years he was seen twice because of AFl and on both occasions 1 mg of ibutilide IV resulted in the return of sinus rhythm with 1:1 AV conduction.Catheter ablation of the arrhythmia is discussed with the patient, to which he agrees and curative AFl ablation is scheduled in 4 weeks. HistoryIn 1906, Einthoven made an electrocardiographic recording of AFl. 1 In 1913, Lewis called attention to the typical saw tooth pattern and the negative deflections of the atrial waves in leads II and III. 2 During the next 50 years, there was much discussion about whether AFl was caused by a rapidly firing atrial focus or is the result of a large circus movement involving the atria.After mapping atrial activation with endocardial and esophageal recordings, Puech et al 3 concluded that the flutter cycle in the human heart involved activation of the whole right atrium.Stimulation studies by Waldo et al 4 revealed that in postoperative AFl the arrhythmia was based on a reentry mechanism involving a large atrial area.They demonstrated the presence of an excitable gap that allowed the speeding up of the flutter rate during atrial pacing and termination of the arrhythmia by pacing.