Coexistence of sick sinus rhythm and atrial flutter-fibrillation.

Abstract

SUMMARY A 58-year-old man with hypertensive cardiovascular disease and atrial flutter underwent electrophysiologic studies, including multiple intra-atrial recordings and atrial stimulation. Although the surface ECG suggested the presence of atrial flutter, intra-atrial recordings demonstrated the presence of (1) sinus-like rhythm localized to an area of approximately 5 mm in and around the region of the sinus node, which was protected by entrance block; (2) flutter and/or fibrillation of the remaining parts of the right atrium; (3) fibrillation of the left atrium; and (4) transient degeneration of flutter into fibrillation at right atrial sites, with predominant flutter activity. Although a major part of the right atrium was in flutter and/or fibrillation, we could assess sinus node function by overdrive stimulation of the area of sinus node activity. Sinus node function studies revealed an underlying sick sinus syndrome.THE DIAGNOSIS of atrial arrhythmias is essentially based on the analysis of the configuration, timing, and rate of P waves on the surface ECG. However, recent studies in selected patients have demonstrated dissimilar atrial rhythms with direct intra-atrial recordings otherwise not discernible on the surface ECG."3 In this paper we report the electrophysiologic findings in a patient in whom the ECG revealed atrial flutter and intra-atrial recordings demonstrated the presence of sinus-like rhythm in and around the region of the sinus node, flutter and/or fibrillation of the remaining parts of the right atrium and fibrillation of the left atrium. We also assessed sinus node function, although a major part of the right and left atria were in flutter and/or fibrillation. Assessment of sinus node function revealed an underlying sick sinus syndrome.Case Report A 58-year-old man with hypertensive cardiovascular disease was admitted to the Medical Service of the Brooklyn Veteran's Administration Medical Center for uncontrolled hypertension, congestive heart failure and atrial flutter of recent onset. A 12-lead ECG suggested the presence of atrial flutter at a rate of 240 beats/min, with a ventricular response of 120 beats/min and poor R-wave progression from V1 to V3 ( fig. 1). Chest x-ray film showed cardiomegaly and pulmonary congestive changes. Echocardiogram revealed left atrial and left ventricular enlargement. The patient's hypertension and congestive heartfailure responded promptly to medical therapy. He was then referred to the cardiology service for elective electrical conversion of the atrial flutter after medical conversion with digitalis and quinidine had failed. Electrophysiologic StudiesThe patient underwent electrophysiologic studies to convert the atrial flutter by overdrive atrial stimulation. The procedure was explained to the patient, who gave signed consent. The electrophysiologic studies were performed after withholding digitalis and quinidine for 2 days. Serum digoxin level was 0.5 ng/ml on the day of the study. Two quadripolar #6FUSCI catheters with 10-mm interelectrode distance ...

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