Atrial Flutter: Lessons from Surgical Interventions (Musing on Atrial Flutter Mechanism)

Abstract

We report our experience with seven patients who underwent direct surgical ablation of problematic common flutter. Intraoperative mapping was obtained in four patients. Surgical techniques varied over time. A circular incision of the right atrium was performed in the first patient. Two patients had epicardial cryoablation of the isthmus between the inferior vena cava and the tricuspid valve annulus. Four patients had extensive endocardial cryoablation of the isthmus. There were no immediate postoperative complications. One patient had atrial fibrillation 2 months postoperatively and underwent a corridor operation 1 year later. The other six patients are free of arrhythmias without antiarrhythmic drugs. Surgical ablation confirmed that the common form of atrial flutter is associated with a right atrial macroreentrant circuit. One of our intraoperative endocardial maps suggested that variant reentrant circuits can be associated with variant forms of flutter.

The Role of Concomitant Arrhythmia Surgery in Patients Undergoing Repair of Congenital Heart Disease

“…Typical atrial flutter was initially surgically treated by Guiraudon et al using an ablation from the tricuspid valve to the inferior vena cava. 3 This lesion effectively interrupted the macro-reentrant circuit coursing up the atrial septum, down the atrial free wall, and through an area of slow conduction in the inferomedial atrial isthmus. Subsequently, the right atrial maze procedure was developed by Cox as part of the Cox-maze procedure for atrial fibrillation.…”

Cryoablation of Cardiac Arrhythmias

“…Some of the early reports of modern cryothermal mapping were provided by the cardiac surgical experience with cryothermal energy [35]. Intraoperative cryoablation has been shown to be safe and effective and has been successfully used in humans to map or ablate the AV node [31], accessory pathways [36], AV nodal re-entrant tachycardia (AVNRT) [37], atrial flutter [38], and VT (in combination with subendocardial resection) [39][40][41].…”

Evolution of Mapping and Anatomic Imaging of Cardiac Arrhythmias

“…The train of knowledge elucidating the mechanisms of atrial flutter has proceeded down a more straightforward track. Although this arrhythmia, as seen in animal and interoperative mapping studies, has been shown to precede via a variety of different reentrant pathways, studies from a number of investigators more clearly established the importance of macroreentry around fixed or functional obstacles, 92 including the tricuspid valve as the site of reentry for isthmus dependent and atypical flutters 93 . In the former case, propagation via the cavotricuspid isthmus has been critical as a central corridor of activation around the tricuspid valve.…”