Interpretation of Typical and Atypical Atrial Flutters by Precision Electrocardiology Based on Intracardiac Recording

  • Fabio M. Leonelli
    Corresponding author. Cardiology Department, James A. Haley Veterans’ Hospital, University of South Florida, 13000 Bruce B Down Boulevard, Tampa FL 33612.
    Cardiology Department, James A. Haley Veterans’ Hospital, University of South Florida, 13000 Bruce B Down Boulevard, Tampa, FL 33612, USA

    University of South Florida FL 4202 E Fowler Avenue, Tampa, FL 33620, USA
    Search for articles by this author
  • Roberto De Ponti
    Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy

    Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
    Search for articles by this author
  • Giuseppe Bagliani
    Cardiology And Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Via Conca 71, Ancona 60126, Italy

    Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, Ancona 60126, Italy
    Search for articles by this author
Published:August 24, 2022DOI:


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Cardiac Electrophysiology Clinics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mines G.R.
        On circulating excitations in heart muscle and their possible relation to tachycardia and fibrillation.
        Trans R Soc Can. 1914; 8: 43-53
        • Lewis T.
        • Drury A.N.
        • Iliescu C.C.
        A demonstration of circus movement in clinical flutter of the auricles.
        Heart. 1921; 8: 341
        • Wells J.L.
        • MacLean W.A.
        • James T.N.
        • et al.
        Characterization of atrial flutter. Studies in man after open heart surgery using fixed atrial electrodes.
        Circulation. 1979; 60: 665-673
        • Wellens H.J.
        Forty years of invasive clinical electrophysiology: 1967-2007.
        Circ Arrhythm Electrophysiol. 2008; 1: 49-53
        • Saoudi N.
        • Cosío F.
        • Waldo A.
        • et al.
        Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a statement from a joint expert group from the working group of arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.
        Eur Heart J. 2001; 22: 1162-1182
        • Kahn A.M.
        • Krummen D.E.
        • Feld G.K.
        • et al.
        Localizing circuits of atrial macro-reentry using ECG planes of coherent atrial activation.
        Heart Rhythm. 2007; 4: 445-451
        • Sippens-Groenewegen A.
        • Lesh M.D.
        • Roithinger F.X.
        et al. Body surface mapping of counterclockwise and clockwise typical atrial flutter: a comparative analysis with endocardial activation sequence mapping.
        J Am Coll Cardiol. 2000; 35: 1276-1287
        • Olgin J.
        • Kalman J.
        • Fitzpatrick A.
        • et al.
        The role of right atrial endocardial structures as barriers to conduction during human type I atrial flutter: activation and entrainment mapping guided by intracardiac echocardiography.
        Circulation. 1995; 92: 1831-1848
        • Olgin J.E.
        • Kalman J.M.
        • Lesh M.D.
        Conduction barriers in human atrial flutter correlation of electrophysiology and anatomy.
        J Cardiovasc Electrophysiol. 1996; 7: 1112-1126
        • Friedman P.A.
        • Luria D.
        • Fenton A.M.
        • et al.
        Global right atrial mapping of human atrial flutter: the presence of posteromedial (sinus venosa region) functional block and double potentials: a study in biplane fluoroscopy and intracardiac echocardiography.
        Circulation. 2000; 101: 1568-1577
        • Perez F.J.
        • Schuber C.M.
        • Parvez B.
        • et al.
        Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter.
        Circ Arrhythmia Electrophysiol. 2009; 4: 393-400
        • Kail J.
        • Glascock D.
        • Kopp D.
        • et al.
        Characterization and catheter ablation of the antidromic form of typical atrial flutter.
        Circulation. 1995; 92 (Abstract): I-I84
        • Yan S.H.
        • Cheng W.J.
        • Wang L.X.
        • Chen M.Y.
        • et al.
        Mechanisms of atypical flutter wave morphology in patients with isthmus-dependent atrial flutter Heart Vessels.
        . 2009; 24: 211-218
        • Allessie M.A.
        • Lammers W.J.E.P.
        • Bonke I.M.
        • et al.
        Intra atrial reentry as a mechanism for atrial flutter induced by acetylcholine and rapid atrial pacing in the dog.
        Circulation. 1984; 70: 123-135
        • Okumura K.
        • Plumb V.J.
        • Page P.L.
        • et al.
        Atrial activation sequence mapping during atrial flutter in the canine pericarditis model and its effects on the polarity of the flutter wave in the electrocardiogram.
        J Am Coll Cardiol. 1991; 17: 509-518
        • Ndrepepa G.
        • Zrenner B.I.
        • Deisenhofer M.
        • et al.
        Relationship between surface electrocardiogram characteristics and endocardial activation sequence in patients with typical atrial flutter.
        Z Kardiol. 2000; 89: 527-537
        • Kalman J.M.
        • Olgin J.E.
        • Saxon L.A.
        • et al.
        Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man: use of activation and entrainment mapping and implications for catheter ablation.
        J Cardiovasc Electrophysiol. 1997; 8: 121-144
        • Saoudi N.
        • Nair M.
        • Abdelazziz A.
        • et al.
        Electrocardiographic patterns and results of radiofrequency catheter ablation of clockwise type I flutter.
        J Cardiovasc Electrophysiol. 1996; 7: 931-942
        • Spach M.S.
        • Miller W.T.
        • Geselowitz D.B.
        • et al.
        The discontinuous nature of propagation in normal canine cardiac muscle. Evidence for recurrent discontinuities of intracellular resistance that affect the membrane currents.
        Circ Res. 1981; 48: 39-54
        • Tai C.T.
        • Chen S.A.
        • Chen Y.J.
        et al. Conduction properties of the crista terminalis in patients with typical atrial flutter: basis for a line of block in the reentrant circuit.
        J Cardiovasc Electrophysiol. 1998; 9: 811-819
        • Tai C.T.
        • Huang J.L.
        • Lee P.C.
        • et al.
        High resolution mapping around the crista terminalis during typical atrial flutter: new insights into mechanisms.
        J Cardiovasc Electrophysiol. 2004; 15: 406-414
        • Yang Y.
        • Cheng J.
        • Bochoyer A.
        • et al.
        Atypical right atrial flutter patterns.
        Circulation. 2001; 103: 3092-3098
        • Zhang S.
        • Younis G.
        • Hariharan R.
        • et al.
        Lower loop reentry as a mechanism of clockwise right atrial flutter.
        Circulation. 2004; 109: 1630-1635
        • Cheng J.
        • Cabeen Jr., W.R.
        • Scheinman M.M.
        Right atrial flutter due to lower loop reentry mechanism and anatomic substrates.
        Circulation. 1999; 99: 1700-1705
        • Kall J.G.
        • Rubenstein D.S.
        • Kopp D.E.
        • et al.
        Atypical atrial flutter originating in the right atrial free wall.
        Circulation. 2000; 101: 270-279
        • Shimizu A.
        • Nozaki A.
        • Rudy Y.
        • et al.
        Onset of induced atrial flutter in the canine pericarditis model.
        J Am Coll Cardiol. 1991; 17: 1223-1234
        • Fujiki A.
        • Nishida K.
        • Sakabe M.
        • et al.
        Entrainment mapping of dual-loop macroreentry in common atrial flutter: new insights into the atrial flutter circuit.
        J Cardiovasc Electrophysiol. 2004; 15: 679-685
        • Yuniadi Y.
        • Tai C.T.
        • et al.
        A new electrocardiographic algorithm to differentiate upper loop Re-entry from Reverse typical atrial flutter.
        J Am Coll Cardiol. 2005; 46: 524-528
        • Rutherford S.L.
        • Trew M.L.
        • Sands G.B.
        • et al.
        High-resolution 3-dimensional reconstruction of the infarct border zone: impact of structural remodeling on electrical activation.
        Circ Res. 2012; 111: 301-311
        • Long Huang J.L.
        • Tai C.-T.
        • Lin Y.-J.
        • et al.
        Substrate mapping to detect abnormal atrial endocardium with slow conduction in patients with atypical right atrial flutter.
        J Am Coll Cardiol. 2006; 48: 492-498
        • Azadani P.N.
        • Kumar U.N.
        • Yang Y.
        • et al.
        Frequency of atrial flutter after adult lung transplantation.
        Am J Cardiol. 2011; 107: 922-926
        • Thajudeen A.
        • Stecker E.
        • Shehata M.,
        • et al.
        Arrhythmias after heart transplantation: mechanisms and management.
        J Am Heart Assoc. 2012; 1: e001461
        • Stevenson I.H.
        • Kistler P.M.
        • Spence S.J.,
        • et al.
        Scar-related right atrial macroreentrant tachycardia in patients without prior atrial surgery: electroanatomic characterization and ablation outcome Heart.
        Rhythm. 2005; 2: 594-601
        • Fukamizu S.
        • Sakurada H.
        • Hayashi T.
        et al. Macroreentrant atrial tachycardia in patients without previous atrial surgery or catheter ablation: clinical and electrophysiological characteristics of scar-related left atrial anterior wall reentry.
        Cardiovasc Electrophysiol. 2013; 24: 404-412
        • Ávila P.
        • Oliver J.M.
        • Gallego P.
        • et al.
        Natural history and clinical predictors of atrial tachycardia in adults with congenital heart disease.
        Circ Arrhythm Electrophysiol. 2017; 10: e005396
        • Quinton E.
        • Nightingale P.
        • Hudsmith L.
        • et al.
        Prevalence of atrial tachyarrhythmia in adults after Fontan operation. Heart.
        . 2015; 101: 1672-1677
        • Wu M.H.
        • Lu C.W.
        • Chen H.C.
        • et al.
        Arrhythmic burdens in patients with tetralogy of Fallot: a national database study.
        Heart Rhythm. 2015; 12: 604-609
        • Gerstenfeld E.P.
        • Callans D.J.
        • Dixit S.
        • et al.
        Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation.
        Circulation. 2004; 110: 1351-1357
        • Chae S.
        • Oral H.
        • Good E.
        • et al.
        Atrial tachycardia after circumferential pulmonary vein ablation of atrial fibrillation: mechanistic insights, results of catheter ablation, and risk factors for recurrence.
        J Am Coll Cardiol. 2007; 50: 1781-1787
        • Latcu D.G.
        • Bun S.-S.
        • Viera F.
        • et al.
        Selection of critical isthmus in scar-related atrial tachycardia using a new automated ultra-high resolution mapping system.
        Circ Arrhythm Electrophysiol. 2016; 9: e004510
        • Nakagawa H.
        • Shah N.
        • Matsudaira K.
        • et al.
        Characterization of reentrant circuit in macroreentrant right atrial tachycardia after surgical repair of congenital heart disease: isolated channels between scars allow “focal” ablation.
        Circulation. 2001; 103: 699-709
        • Jaïs P.
        • Shah D.C.
        • Haissaguerre M.
        • et al.
        Mapping and ablation of left atrial flutters.
        Circulation. 2000; 101: 2928-2934
        • Ng F.S.
        • Guerrero F.
        • Luther V.
        • et al.
        Microreentrant left atrial tachycardia circuit mapped with an ultra-high-density mapping system Heart Rhythm Case.
        Rep. 2017; 3: 224-228
        • Roberts-Thomson K.C.
        • Kalman J.M.
        Right septal macroreentrant tachycardia late after mitral valve repair: importance of surgical access approach Heart.
        Rhythm. 2007; 4: 32-36
        • Chan D.P.
        • Van Hare G.F.
        • Mackall J.A.
        • et al.
        Importance of atrial flutter isthmus in postoperative intra-atrial reentrant tachycardia.
        Circulation. 2000; 102: 1283-1289
        • Wasmer K.
        • Kobe J.
        • Dechering D.G.
        • et al.
        Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial septal defect repair.
        Int J Cardiol. 2013; 168: 2447-2452
        • Collins K.K.
        • Love B.A.
        • Walsh E.P.
        • et al.
        Location of acutely successful radiofrequency catheter ablation of intra atrial reentrant tachycardia in patients with congenital heart disease.
        Am J Cardiol. 2000; 86: 969-974
        • Olgin J.E.
        • Kalman J.M.
        • Saxon L.A.
        • et al.
        Mechanism of initiation of atrial flutter in humans: site of unidirectional block and direction of rotation.
        J Am Coll Cardiol. 1997; 29: 376-384
        • Lukac P.
        • Pedersen A.K.
        • Mortensen P.T.
        • et al.
        Ablation of atrial tachycardia after surgery for congenital and acquired heart disease using an electroanatomic mapping system: which circuits to expect in which substrate?.
        Heart Rhythm. 2005; 2: 64-72
        • Yang Y.
        • Varma N.
        • Badhwar N.
        • et al.
        Prospective observations in the clinical and electrophysiological characteristics of intra-isthmus re-entry.
        Cardiovasc Electrophysiol. 2010; 21: 1099-1106
        • Marrouche N.F.
        • Natale A.
        • Wazni O.M.
        • et al.
        Left septal atrial flutter: electrophysiology, anatomy, and results of ablation.
        Circulation. 2004; 109: 2440-2447
        • Fiala M.
        • Chovancik J.
        • Neuwirth R.
        • et al.
        Atrial macro reentry tachycardia in patients without obvious structural heart disease or previous cardiac surgical or catheter intervention: characterization of arrhythmogenic substrates, reentry circuits, and results of catheter ablation.
        J Cardiovasc Electrophysiol. 2007; 18: 824-832
      1. Jhang J, Tang C, Zhang Y, et al. Electroanatomic characterization and ablation outcome of non-lesion related left atrial macroreentrant tachycardia in patients without obvious structural heart disease. J Cardiovasc Electrophysiol DOI:10.1111/j.1540-8167.2012.02426

        • Markowitz S.M.
        • Brodman R.F.
        • Stein K.M.
        • et al.
        Lesional tachycardias related to mitral valve surgery.
        J Am Coll Cardiol. 2002; 39: 1973-1983
        • Cox J.L.
        • Jaquiss R.D.
        • Schuessler R.B.
        • et al.
        Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure.
        J Thorac Cardiovasc Surg. 1995; 110: 485-495
        • Gillinov A.M.
        • McCarthy P.M.
        Advances in the surgical treatment of atrial fibrillation.
        Cardiol Clin. 2004; 22: 147-157
        • Park H.E.
        • Kim K.-H.
        • Kim K.-B.
        • et al.
        Characteristics of P wave in patients with sinus rhythm after maze operation.
        J Korean Med Sci. 2010; 25: 712-715
        • Takahashi Y.
        • O’Neill M.D.
        • Hocini M.
        • et al.
        Effects of stepwise ablation of chronic atrial fibrillation on atrial electrical and mechanical properties.
        J Am Coll Cardiol. 2007; 49: 1306-1314
        • Wasmer K.
        • Mö nnig G.
        • Bittner A.
        • et al.
        Incidence, characteristics, and outcome of left atrial tachycardias after circumferential antral ablation of atrial fibrillation.
        Heart Rhythm. 2012; 9: 1660-1666
        • Knecht S.
        • Veenhuyzen G.
        • O’Neill M.
        • et al.
        Atrial tachycardias encountered in the context of catheter ablation for atrial fibrillation part II: mapping and ablation.
        PACE. 2009; 32: 528-538
        • Jais P.
        • Matsuo S.
        • Knecht S.,
        • et al.
        A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: importance of localized reentry.
        J Cardiovasc Electrophysiol. 2009; 20: 480-491
        • Pascale P.
        • Roten L.
        • Shah A.,
        • et al.
        Useful electrocardiographic features to help identify the mechanism of atrial tachycardia occurring after persistent atrial fibrillation ablation.
        J Am Coll Cardiol. 2018; 4: 33-45
        • Jais P.
        • Sanders P.
        • Hsu L.-F.
        • et al.
        Flutter localized to the anterior left atrium after catheter ablation of atrial fibrillation.
        J Cardiovasc Electrophysiol. 2006; 17: 279-285
        • Hocini M.
        • Jais P.
        • Sanders P.
        • et al.
        Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study.
        Circulation. 2005; 112: 3688-3696
        • Gerstenfeld E.
        • Dixit S.
        • Bala R.
        • et al.
        Surface electrocardiogram characteristics of atrial tachycardias occurring after pulmonary vein isolation Circ.
        Arrhythm Electrophysiol. 2013; 6: 481-490
        • Mesas C.E.E.
        • Pappone C.
        • Lang C.C.E.
        • et al.
        Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation: electroanatomic characterization and treatment.
        J Am Coll Cardiol. 2004; 44: 1071-1079
        • Shrestha S.
        • Chen O.
        • Greene M.
        • et al.
        Change in P wave morphology after convergent atrial fibrillation ablation.
        Indian Pacing Electrophysiol J. 2016; 16: 3-7
        • Jonathan Buber J.
        • Luria D.
        • Sternik L.
        • et al.
        . Morphological features of the P-waves at surface electrocardiogram as surrogate to mechanical function of the left atrium following a successful modified maze procedure.
        Europace. 2014; 16: 578-586
        • Bochoeyer A.
        • Yang Y.
        • Cheng J.
        • et al.
        Surface electrocardiographic characteristics of right and left atrial flutter.
        Circulation. 2003; 108: 60-66
        • Medi C.
        • Kalman J.M.
        Prediction of the atrial flutter circuit location from the surface electrocardiogram.
        Europace. 2008; 10: 786-796
        • Brown J.P.
        • Krummen D.E.
        • Feld G.K.
        • et al.
        Using electrocardiographic activation time and diastolic intervals to separate focal from macro–re-entrant atrial tachycardias.
        J Am Coll Cardiol. 2007; 49: 1965-1973
        • Shah D.
        • Sunthorn H.
        • Burri H.
        • et al.
        Narrow, slow-conducting isthmus dependent left atrial reentry developing after ablation for atrial fibrillation: ECG characterization and elimination by focal RF ablation.
        J Cardiovasc Electrophysiol. 2006; 17: 508-515
        • Lee J.M.
        • Turner I.
        • Agarwal A.
        • et al.
        An unusual atrial tachycardia in a patient with Friedreich ataxia.
        Europace. 2011; 13: 1660-1661
        • Huo Y.
        • Schoenbauer R.
        • Richter S.
        • et al.
        Atrial arrhythmias following surgical AF ablation: electrophysiological findings, ablation strategies, and clinical outcome.
        J Cardiovasc Electrophysiol. 2014; 25: 725-738
        • Casado Arroyo R.
        • Laţcu D.G.
        • Maeda S.
        • et al.
        Coronary sinus activation and ECG characteristics of roof-dependent left atrial flutter after pulmonary vein isolation.
        Circ Arrhythm Electrophysiol. 2018; 11: e005948
        • Chugh A.
        • Latchamsetty R.
        • Oral H.
        • et al.
        Characteristics of cavotricuspid isthmus–dependent atrial flutter after left atrial ablation of atrial fibrillation.
        Circulation. 2006; 113: 609-615
        • Gopinathannair R.
        • Mar P.L.
        • Afzal M.R.
        • et al.
        Atrial tachycardias after surgical atrial fibrillation ablation: clinical characteristics, electrophysiological mechanisms, and ablation outcomes from a large, multicenter study.
        J Am Coll Cardiol EP. 2017; 3: 865-874
        • Chyou J.Y.
        • Hickey K.
        • Diamond L.
        • et al.
        Atypical electrocardiographic features of cavo tricuspid isthmus-dependent atrial flutter occurring during left atrial fibrillation ablation.
        Ann Noninvasive Electrocardiol. 2010; 15: 200-208
        • Ashino S.
        • Watanabe I.
        • Okumura Y.
        • et al.
        Change in atrial flutter wave morphology—insight into the sources of electrocardiographic variants in common atrial flutter.
        PACE. 2007; 30: 1023-1026
        • Chang S.-L.
        • Tsao H.-M.
        • Lin Y.-J.
        • et al.
        Differentiating macroreentrant from focal atrial tachycardias occurred after circumferential pulmonary vein isolation.
        J Cardiovasc Electrophysiol. 2011; 22: 748-755
        • Kistler P.M.
        • Kurt C.
        • Roberts-Thomson K.C.
        • et al.
        P-wave morphology in focal atrial tachycardia: development of an algorithm to predict the anatomic site of origin.
        J Am Coll Cardiol. 2006; 48: 1010-1017
        • Rajawat Y.S.
        • Gerstenfeld E.P.
        • Patel V.V.
        • et al.
        ECG criteria for localizing the pulmonary vein origin of spontaneous atrial premature complexes: validation using intracardiac recordings.
        Pacing Clin Electrophysiol. 2004; 27: 182-188
        • Yamada T.
        • Murakami Y.
        • Yoshida Y.
        • et al.
        Electrophysiologic and electrocardiographic characteristics and radiofrequency catheter ablation of focal atrial tachycardia originating from the left atrial appendage.
        Heart Rhythm. 2007; 4: 1284-1291