Frédéric Anselme CHU de Rouen A Flutter... · Flutter par Réentrée Supérieure Intra-Auriculaire Droite-Patients sans ATCD de chir. Card.-Incidence faible (8/150 pts avec ECG

Atypical Atrial Flutter

Frédéric Anselme

CHU de Rouen

DIU Rythmologie 2020

Définition

• Flutter auriculaire : Tachycardie auriculaire régulière, > 240/min, avec absence de retour à la ligne isoélectrique entre 2 déflections auriculaires dans au moins 1 dérivation ECG.

Mécanisme : macro-réentrée auriculaire

• Atypique : dont le circuit de réentrée ne dépend pas de l’isthme cavo-tricuspide.

En Pratique

• ECG ECG de flutter typique

• Diagnostic établi par la cartographie

• Plus rares que le flutter typique

• Patients avec cardiopathie

• Association fréquente avec AC/FA

• Post ablation de FA ++

• Localisation auriculaire droite ou gauche

Flutters Auriculaires Atypiques

Circuits de macro-réentrée

• Autour d’obstacles anatomiques (ostia, anneau mitral, Crista terminalis, sinus coronaire)

• Autour de cicatrices chirurgicales ou de patchs

• Autour de zones inexcitables (cardiopathies)

Moyens d’investigation

• Cathéters multipolaires et cartographie utilisant la technique de l’entraînement

• Systèmes de cartographie tridimensionnelle- Carto, NavX, Rhythmia …

Technique de l’entraînement

t Cycle = xCycle de retour

=cycle tachyc. + 2t

P stim. P tachyc.

I

CS-P

Isthm

Halo-D

Halo-M

Halo-P

II

III

aVR

V1

V6

380380 420 420

Cycle = x

Cycle = x

Cycle de retour =

cycle tachyc.

P stim. P tachyc.

Cycle de retour =

cycle tachyc.

P stim. = P tachyc.

• I- Les FlA isthmiques dépendants à ECG atypique

- Flutter isthm. dépendant, à rot. anti-horaire, à ECG atypique

- Flutter isthm. dépendant à rot. horaire

• II- Les tachycardies atriales focales avec aspect ECG de flutter atypique

• III- Les FlA atypiques

I

II

III

aVL

aVF

V1V2

V3

V4

V5

aVR

V6

II

III

V1

Isthm.

H1H2

H3H4

H5H6

H7H8

H9H10

H11H12

H13H14

Flutter Auriculaire AtypiqueÀ ECG de Flutter Typique



• III-Les FlA atypiques

Tachycardie Atriale Focale Avec Aspect ECG de Flutter A. Atypique

I

II

III

aVr

aVlaVf

V1

V2

V3

V4

V5

V6

Aspect ECG ne préjuge pas

du mécanisme de l’arythmie



• III-Les FlA atypiques

- Macro-réentrée auriculaire droite non incisionelle - Macro-réentrée auriculaire droite incisionelle- Macro-réentrée auriculaire gauche- Macro-réentrée utilisant la musculature du SC

Flutter par Réentrée SupérieureIntra-Auriculaire Droite

CT

FO

SC

IVC

SVC

AT

ER

Flutter par Réentrée SupérieureIntra-Auriculaire Droite

- Patients sans ATCD de chir. Card.

- Incidence faible (8/150 pts avec ECG de flutter typique ou atypique)

- Ablation au niveau du gap de conduction dans la Crista Terminalis

Ching-Tai T et al, JACC 2002;40:746Incidence OPD

I

II

III

aVr

aVl

aVf

V1

V2

V3V4

V5V6

Flutter Auriculaire Post-Atriotomie

Flutter Auriculaire Post-Atriotomie

Double Réentrée auriculaire droite- 10/21pts souffrants de Flutter après correction chir. de CIA

- Atriotomie antérieure et incomplète vers la VCI

Shah DP et al, Circulation 2000 15;101:631

Flutters Auriculaires Gauches

Jais P, et al, Circulation 2000;101:2928P + en V1

When should we consider LA Flutter ?

• ECG: Predominantly positive F wave in V1

Low voltage F Waves in inferior leads

In all pt with an ECG not characteristic of typical atrial flutter

• Presence of hemodynamically significant left HD

• History of open heart surgery

• History of AFib ablation procedure

• Entrainment mapping excluding RA during EP study

Bochoeyer, Yang et Al. Circulation. 2003;108:6

Diagnosis is not a problem

Jaïs et Al:

Circulation 2000,

101: 2928

Various Types of LA CircuitsIn absence of prior LA « surgery »

• Low incidence

• Conventional entrainment mapping , look for fractionated egm

• 3D mapping systems +++

• Electrically silent areas in 50% of the pts

• Multiple circuits bounded by anatomical structures and scar zones

Ablation of « spontaneous » LA FlutterThe Bordeaux experience

• N= 22 pts

• 1, 2, 3 sessions in 14, 7, and 1 patients respectively

• Cumulative procedure time: 339±113 min

• Cumulative fluo. time: 95±42 min

Jaïs et Al: Circulation 2000, 101: 2928

• Incomplete map in 5/22 pts

• 1 pt with reversible stroke

• Acute success (SR): 20/22 pts

• Mid term FU: Permanent Afib in 1, atypical AF in 5 pts (23%)

Ablation of LA FlutterThe Hamburg experience

• 28 pts

• Critical isthmus identification in 89% during AFl

• Isthmus identification in SR in 2 pts

• Isthmus width: 12±6mm

• AFl termination in 23 pts

• PT: 384±145 min

• FT: 18.4±8.8 min

Ouyang F, et al. Circulation 2002;105:1934

Validation of isthmus conduction blockduring SR or pacing

• LA flutter recurrences in 3/28 pts (11%)

• No recurrences if validated isthmus conduction block

• Afib in 6/28 (21%) at a median FU of 14 months

Ouyang F, et al.

Circulation

2002;105:1934

Septal LA flutter In absence of prior LA « surgery »

Marrouche n, et Al: Circulation 2004, 109: 2440• High amplitude in V1

• Flat in inferior leads

Left Septal Flutter Ablation

• SP-MA isthmus ablation more efficient than that of SP-RPV isthmus

• Acute success in 10/11 pts

• Recurrences in 2/11 pts

• Afib in 2/11 pts

Marrouche n, et Al: Circulation 2004, 109: 2440

Organized Arrhythmia post-AFib Ablation

• Incidence ~ 8% after AFib ablation (1.2-21%)

higher if linear lesions applied during the index procedure

• PV tachycardia with LA reconnection

• Reentry at gaps within the ablation line

• Macro-reentry bounded by PVs and scar zones

• Localized LA reentry

Jais P, et al. JCE 2006;17:279

Correlation ECG/Mechanism• Continuous electrical activity in at

least 1 ECG lead• Lack of continuous electrical

activity in all ECG leads

III

III

aVL

aVF

V1

V2

V3

V4

V5

V6

aVR

III

III

aVL

aVF

V1

V2

V3

V4

V5

V6

aVR

Atrial Tachycardia Atrial Flutter

Focus

Macro-reentry

In patients with prior Afib ablation, LAMRT should always be

considered whatever the ECG pattern

Stepwise Approach to Diagnose Post Afib AT

• 1- Assessment of AT CL stability with a decapolar CS catheter:

- CS activation sequence

- TCL variability > 15% suggests focal AT

• 2- Exclude typical flutter using IVC-TA isthmus entrainment maneuvers

I

II

III

aVL

aVF

V1

V2

V3

V4

V5

aVR

V6

II

III

V1

Isthm.

H1H2

H3H4

H5H6

H7H8

H9H10

H11H12

H13H14

• 3- Exclude PV dependent AT by checking PV isolation with a lasso cath.


RSPV Mapping RSPV Isolation

• 4- Diagnosis of macroreentry circuits :


* **

• 2 possible isthmuses:

- LA roof

- Mitral isthmus

• 4- Diagnosis of macroreentry circuits :


• Activation mapping with

a roving catheter•Both ant and post walls

activated in the same direction

excludes roof dependent

macroreentry

• Entrainment maneuvers

at opposite LA walls:

- MI & septal

- post & ant •PPI>TCL+30 ms at one of the

opposite walls excludes

perimitral or roof dependent

macroreentry respectively

Reference potential at the CS

****

Musculature du Sinus Coronaire Arythmogène

Olgin JE, et al. JCE 1998;9:1094

Macro-réentrée utilisant la musc. du SC

Schéma du Flutter Auriculaire Atypiquedépendant de la musculature du sinus coronaire

Olgin JE, et al. JCE 1998;9:1094

Site d’ablation

Long term outcome after LA Flutter Ablation

• Up to 20% of LA Flutter recurrences

less if validated isthmus conduction block

• High incidence of AFib likely due to the progression of the underlying heart disease

Baseline ECGClinical Case #1

CS Mapping at Start

LA Roof Entrainment

PPI = TCL + 100 msec

LA Septal Entrainment

PPI = TCL

MI Entrainment

PPI = TCL

Question # 1• LA roof is not part of the tachycardia circuit

• Result of MI entrainment is sufficient enough to diagnose perimitral macrorentry

• Result of MI entrainment is sufficient enough to perform MI ablation

Roof entrainment

MI entrainment

Tachycardia termination during MI ablation

Answer # 1• LA roof is not part of the tachycardia circuit: PPI>>> TCL

• Result of MI entrainment is sufficient enough to diagnose perimitral macrorentry

• Result of MI entrainment is sufficient enough to perform MI ablation

- Both LA septal and MI

entrainment are required to

diagnose perimitral flutter.

Other macroreentries

utilizing MI are possible

- As soon as the MI is

recognized as part of the

tachycardia circuit, MI

ablation can be perform

LAA Pacing

Question # 2

• I pace the lateral part of the MI line to confirm clockwise MI block

• I pace the CS to confirm counterclockwise MI block

• There is complete MI block, I stop the ablation procedure

• There is still residual MI conduction

LAA pacing

Answer # 2

• I pace the lateral part of the MI line to confirm clockwise MI block

• I pace the CS to confirm counterclockwise MI block

• There is complete MI block, I stop the ablation procedure

• There is still residual MI conduction

LAA pacing

CS activation is from distal to proximal which identifies residual MI conduction

**

During MI ablation

dCS Pacing at septal side of the MI line

*****

Abl Cath on MI line

Wide double potentials recorded at MI line

identifying counterclockwise MI block

**

* * * *

Baseline ECGClinical Case #2

CS Mapping at Start

Question # 3

• CS activation is typical of perimitral macroreentry and I start ablating the MI?

• CS electrograms reflect LA and CS musculature activation ?

• I ablate within the CS to disconnect CS musculature ?

• I perform activation mapping with the LA?

• I perform entrainment at IVC-TA isthmus ?

Answer # 3

• CS activation is typical of perimitral

macroreentry and I start ablating the MI?

• CS electrograms reflect LA and CS musculature

activation ?

• I ablate within the CS to disconnect CS

musculature ?

• I perform activation mapping with the LA?

• I perform entrainment at IVC-TA isthmus ?

-CS is activated almost synchronously, which does not suggest perimitral

macroreentry

-Always best to understand tachycardia mechanism before ablation

-It is worth to do IVC-TA entrainment to exclude typical flutter even if the surface

ECG and the CS activation are not suggestive. Prior extensive LA/RA ablation (CS

os) may modify the usual typical flutter ECG pattern and atrial activation

MI Entrainment

LA Roof Entrainment

Question # 4• MI entrainment suggest MI dependent macroreentry

• LA roof entrainment suggest roof dependent macroreentry

• I cannot conclude and I perform anterior and posterior activation mapping

• I proceed to roof line ablation

• I perform LA septal entrainment

MI Entrainment

LA Roof Entrainment

Answer # 4

• MI entrainment suggest MI dependent macroreentry

• LA roof entrainment suggest roof dependent macroreentry

• I cannot conclude and I perform anterior and posterior activation mapping

• I proceed to do roof line ablation


-Long PPI excludes MI from the tachycardia circuit

-LA septal entrainment is not mandatory, result from LA roof

entrainment is enough to proceed to do roof line ablation

MI Entrainment

PPI>TCL+30 msec

CS Mapping after Roof Line Ablation

Question # 5• The macroreentry was not LA roof dependent

• Conduction gap within the roof line cannot be excluded

• CS 7-8 shows continuous fragmented atrial electrograms covering more than 70% of the TCL supporting ablation at that site

• I perform MI and/or LA septal entrainment

• I do activation mapping around the mitral annulus

Answer # 5• The macroreentry was not LA roof dependent

• Conduction gap within the roof line cannot be excluded

• CS 7-8 shows continuous fragmented atrial electrograms covering more than 70% of the TCL supporting ablation at that site

• I perform MI and/or LA septal entrainment

• I do activation mapping around the mitral annulus

-TCL prolongation suggests the tachycardia was LA roof dependent

-Even if CS activation sequence is modified, LA roof line conduction gap can not be excluded

-Intermittent block within CS fragmented potentials suggests dead end pathway

MI Entrainment

PPI = TCL + 20 msec : this site is part of the tachy circuit

During Endocardial MI Ablation

Question # 6

• There is block at the MI

• I check the roof line

• I perform MI entrainment


• I look for a focal atrial tachycardia

Answer # 6• There is block at the MI

• I check the roof line




- Identical CS activation sequence suggests residual conduction MI

- Need to map the epicardial side of the MI

dCS Entrainment

PPI=TCL: Epicardial MI ablation is performed

After Epicardial MI Ablation

Prolongation of the TCL (468 to 492 msec)

Modification of the CS activation sequence

Question # 7

• There is complete block at the MI

• I perform IVC-TA entrainment




Answer # 7

• There is complete block at the MI

• I perform IVC-TA entrainment




-Change of CS activation sequence and TCL prolongation suggest tachycardia

circuit does not depend on MI anymore

-However, residual MI conduction cannot be excluded

-Because of the CS activation sequence (pCS dCS) IVC-TA and LA septal

entrainment are useful to exclude RA or septal macroreentry

Mapping with the Lasso Catheter between LAA and LPVs

Question # 8

• Electrograms recorded at the lasso catheter are far field potentials from both LAA and PVs

• Lasso 15-16 electrograms may reflect localized reentry

• I perform entrainment maneuvers at Lasso 15-16

• I perform entrainment maneuvers at dAbl

• I move the Lasso catheter to another area

Answer # 8• Electrograms recorded at the lasso catheter are far field

potentials from both LAA and PVs

• Lasso 15-16 electrograms may reflect localized reentry

• I perform entrainment maneuvers at Lasso 15-16

• I perform entrainment maneuvers at dAbl

• I move the Lasso catheter to another area

SR Restoration during RF Ablation

- Lasso has been moved towards LAA

- Ablation performed at site where the lasso

15-16 electrodes had been positioned

Documents

Frédéric Anselme CHU de Rouen A Flutter... · Flutter par Réentrée Supérieure Intra-Auriculaire Droite-Patients sans ATCD de chir. Card.-Incidence faible (8/150 pts avec ECG