CLINICAL CONFERENCE

CLINICAL CONFERENCE

By Faizul Haque

Date Presented: 12/4/2007

Department of Cardiology

University of Illinois at Chicago

By Faizul Haque

Date Presented: 12/4/2007

Department of Cardiology

University of Illinois at Chicago

• 58 y/o F who had initially presented to outside hospital for severe palpitations + lightheadedness:– she states the sx of palpitations started within

2d prior to recent admission: she has had intermittent hx of palpitations since 2003

– she has had some associated LH: denies any syncopal episodes

– patient denies any CP/SOB/DOE per review– Patient referred to UIC EP for further

evaluation/management

• 58 y/o F who had initially presented to outside hospital for severe palpitations + lightheadedness:– she states the sx of palpitations started within

2d prior to recent admission: she has had intermittent hx of palpitations since 2003

– she has had some associated LH: denies any syncopal episodes

– patient denies any CP/SOB/DOE per review– Patient referred to UIC EP for further

evaluation/management

CASE

• pMHx/pSurghx:– Hx of mitral stenosis + severe MR

• MVR+TV repair in 4/2004 at outside hospital• Redo bioprosthetic MVR + TV repair recently in

8/07 at outside hospital

– Hx of HTN– Hx of depression– Hx of HL

• pMHx/pSurghx:– Hx of mitral stenosis + severe MR

• MVR+TV repair in 4/2004 at outside hospital• Redo bioprosthetic MVR + TV repair recently in

8/07 at outside hospital

– Hx of HTN– Hx of depression– Hx of HL

Past Hx

• O: V/S – 97.1 – 104/60 - ~100bpm• Gen: NAD; resting upright• Neck: JVP at 6cmH20• Chest: b/l CTA; no wheezes or crackles

noted• CV: rr nl s1s2 no s3s4 noted; no RV

impulse • Abd: +BS• Ext: no b/l LEE noted

• O: V/S – 97.1 – 104/60 - ~100bpm• Gen: NAD; resting upright• Neck: JVP at 6cmH20• Chest: b/l CTA; no wheezes or crackles

noted• CV: rr nl s1s2 no s3s4 noted; no RV

impulse • Abd: +BS• Ext: no b/l LEE noted

Physical Exam:

• Medications: current– Metoprolol 12.5mg BID– ASA 325mg qD– Lasix 20mg qD– Zocor 20mg qHS

coumadin 5mg + 2.5mg alternating qD

• Medications: current– Metoprolol 12.5mg BID– ASA 325mg qD– Lasix 20mg qD– Zocor 20mg qHS

coumadin 5mg + 2.5mg alternating qD

Med Hx:

• TTE: 11/07– 1. Left atrium mildly dilated: 4.41cm– 2. Global normal LV function: EF 50-55%– 3. Global normal RV size + function– 4. Peak TV TR at 2.7m/sec, PA 38mmHg

• TTE: 11/07– 1. Left atrium mildly dilated: 4.41cm– 2. Global normal LV function: EF 50-55%– 3. Global normal RV size + function– 4. Peak TV TR at 2.7m/sec, PA 38mmHg

Clinical Questions:

• Prototypic macroreentrant atrial rhythm

• Typical/atypical atrial flutter:• Reentrant rhythm in the R atrium constrained

anteriorly by the tricuspid annulus and posteriorly by the crista terminalis and eustachian ridge

• Typical atrial flutter usually defined by counterclockwise versus clockwise rotation along the macroreentrant circuit

• Prototypic macroreentrant atrial rhythm

• Typical/atypical atrial flutter:• Reentrant rhythm in the R atrium constrained

anteriorly by the tricuspid annulus and posteriorly by the crista terminalis and eustachian ridge

• Typical atrial flutter usually defined by counterclockwise versus clockwise rotation along the macroreentrant circuit

Atrial Flutter: Basics

Hx

• Typical atrial flutter [Type I]• Identically recurring sawtooth flutter [F] waves best

visualized in II, III, AVf + V1• Inverted [negative] flutter waves in II, III, AVf due to

counterclockwise reentry• Upright [positive] flutter waves in II, III, AVf present

during clockwise reentry• Involves the cavotricuspid isthmus [CTI]

• Atypical atrial flutter• Not involving CTI: could be from prior atrial

surgery/ablation, idiopathic fibrosis, L atrial origination around the mitral annulus

• Typical atrial flutter [Type I]• Identically recurring sawtooth flutter [F] waves best

visualized in II, III, AVf + V1• Inverted [negative] flutter waves in II, III, AVf due to

counterclockwise reentry• Upright [positive] flutter waves in II, III, AVf present

during clockwise reentry• Involves the cavotricuspid isthmus [CTI]

• Atypical atrial flutter• Not involving CTI: could be from prior atrial

surgery/ablation, idiopathic fibrosis, L atrial origination around the mitral annulus

Aflutter: ECG Criteria

• Which patients are considered ideal candidates for catheter-based atrial flutter ablation?

• Ideally patients with cavotricuspid isthmus dependent atrial flutter or typical atrial flutter as opposed to atypical CTI-independent scenarios

• Which patients are considered ideal candidates for catheter-based atrial flutter ablation?

• Ideally patients with cavotricuspid isthmus dependent atrial flutter or typical atrial flutter as opposed to atypical CTI-independent scenarios

Clinical Questions:

Aflutter Ablation

Clinical Questions:

Clinical Questions: