THREE CASES AND REVIEW OF THE LITERATURE. Circulation 1964; 29:SUPPL:593. https://www.uptodate.com/contents/overview-of-atrial-flutter/print 12/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate 7. FRIEDBERG CK, DONOSO E. Arrhythmias and conduction disturbances due to digitalis. Prog Cardiovasc Dis 1960; 2:408. 8. Friedberg CK. Diseases of the Heart, Saunders, Philadelphia 1966. 9. Lewis T. Diseases of the Heart, MacMillan, London 1948. 10. Alboni P, Scarf S, Fuc G, et al. Atrial and ventricular pressures in atrial flutter. Pacing Clin Electrophysiol 1999; 22:600. 11. Wellens HJ. Contemporary management of atrial flutter. Circulation 2002; 106:649. 12. Vos MA, Golitsyn SR, Stangl K, et al. Superiority of ibutilide (a new class III agent) over DL- sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group. Heart 1998; 79:568. 13. Stambler BS, Wood MA, Ellenbogen KA. Antiarrhythmic actions of intravenous ibutilide compared with procainamide during human atrial flutter and fibrillation: electrophysiological determinants of enhanced conversion efficacy. Circulation 1997; 96:4298. 14. Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation 1996; 94:1613. 15. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. 16. Crijns HJ, Van Gelder IC, Tieleman RG, et al. Long-term outcome of electrical cardioversion in patients with chronic atrial flutter. Heart 1997; 77:56. 17. Halligan SC, Gersh BJ, Brown RD Jr, et al. The natural history of lone atrial flutter. Ann Intern Med 2004; 140:265. 18. Spector P, Reynolds MR, Calkins H, et al. Meta-analysis of ablation of atrial flutter and supraventricular tachycardia. Am J Cardiol 2009; 104:671. 19. Maskoun W, Pino MI, Ayoub K, et al. Incidence of Atrial Fibrillation After Atrial Flutter Ablation. JACC Clin Electrophysiol 2016; 2:682. 20. Lanzarotti CJ, Olshansky B. Thromboembolism in chronic atrial flutter: is the risk underestimated? J Am Coll Cardiol 1997; 30:1506. 21. Writing Group Members, January CT, Wann LS, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A https://www.uptodate.com/contents/overview-of-atrial-flutter/print 13/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2019; 16:e66. Topic 1048 Version 43.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 14/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate GRAPHICS Reentrant circuit of typical atrial flutter within the right atrium Schematic representation of reentrant circuit (red arrow) of typical (type 1) atrial flutter. The reentrant impulse rotates in a counterclockwise direction around the tricuspid annulus. The crista terminalis (CT) and eustacian ridge (ER) serve as lines of block, preventing the impulse from short-circuiting the annulus. Ablation is performed in the isthmus between the IVC and TA, which is an obligatory part of the circuit. SVC: superior vena cava; CS: coronary sinus; IVC: inferior vena cava; FO: foramen ovale Graphic 52904 Version 5.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 15/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate Electrical activation of the right atrium in atrial flutter Electroanatomical (3D) mapping using the CARTO system. The right atrium (RA) is depicted in the LAO projection. The circular "cutout" area in the forefront of the picture represents the tricuspid valve annulus. The red area is the inferolateral RA, the yellow-green area at the bottom of the picture is near the inferior vena cava, the yellow dots are at the region of the His bundle (AV node), and the blue area is the superior RA. The top of the picture is the superior vena cava region. The color (red-orange-yellow-green-blue-purple) represents the direction of electrical activation in the RA during typical (counterclockwise) atrial flutter. Each flutter wave seen on ECG represents a single electrical activation of this entire circuit. Graphic 89570 Version 1.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 16/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate ECG of counterclockwise typical atrial flutter Sawtooth-like oscillations of baseline between flutter waves, best seen in the inferior leads. Negative flutter waves in II, III, aVF, V6. Positive flutter waves in V1. ECG: electrocardiogram. Graphic 89571 Version 2.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 17/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate ECG of clockwise typical atrial flutter Sawtooth-like oscillations of baseline between flutter waves, best seen in inferior leads. Positive flutter waves in II, III, aVF, V6. Negative flutter waves in V1. ECG: electrocardiogram. Graphic 89576 Version 2.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 18/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate ECG of atypical atrial flutter Note the lack of classic sawtooth flutter waves in the inferior leads II, III, and aVF. ECG: electrocardiogram. Graphic 89577 Version 4.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 19/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate Revised (2018) Vaughan Williams classification of antiarrhythmic drugs abridged table Class 0 (HCN channel blockers) Ivabradine Class I (voltage-gated Na+ channel blockers) Class Ia (intermediate dissociation): Quinidine, ajmaline, disopyramide, procainamide Class Ib (rapid dissociation): Lidocaine, mexilitine Class Ic (slow dissociation): Propafenone, flecainide Class Id (late current): Ranolazine Class II (autonomic inhibitors and activators) Class IIa (beta blockers): Nonselective: carvedilol, propranolol, nadolol Selective: atenolol, bisoprolol, betaxolol, celiprolol, esmolol, metoprolol Class IIb (nonselective beta agonists): Isoproterenol Class IIc (muscarinic M2 receptor inhibitors): Atropine, anisodamine, hyoscine, scopolamine Class IId (muscarinic M2 receptor activators): Carbachol, pilocarpine, methacholine, digoxin Class IIe (adenosine A1 receptor activators): Adenosine Class III (K+ channel blockers and openers) Class IIIa (voltage dependent K+ channel blockers): Ambasilide, amiodarone, dronedarone, dofetilide, ibutilide, sotalol, vernakalant Class IIIb (metabolically dependent K+ channel openers): https://www.uptodate.com/contents/overview-of-atrial-flutter/print 20/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate Nicorandil, pinacidil Class IV (Ca++ handling modulators) Class IVa (surface membrane Ca++ channel blockers): Bepridil, diltiazem, verapamil Class IVb (intracellular Ca++ channel blockers): Flecainide, propafenone Class V (mechanosensitive channel blockers): No approved medications Class VI (gap junction channel blockers) No approved medications Class VII (upstream target modulators) Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Omega-3 fatty acids Statins HCN: hyperpolarization-activated cyclic nucleotide-gated; Na: sodium; K: potassium; Ca: calcium. Graphic 120433 Version 3.0 https://www.uptodate.com/contents/overview-of-atrial-flutter/print 21/22 7/5/23, 10:22 AM Overview of atrial flutter - UpToDate Contributor Disclosures Robert Phang, MD, FACC, FHRS No relevant financial relationship(s) with ineligible companies to disclose. Jordan M Prutkin, MD, MHS, FHRS No relevant financial relationship(s) with ineligible companies to disclose. Peter J Zimetbaum, MD Consultant/Advisory Boards: Abbott Medical [Lead extraction]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/overview-of-atrial-flutter/print 22/22