Mapping the conversion of atrial flutter to atrial fibrillation and atrial fibrillation to atrial flutter. Insights into mechanisms

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Circulation Research. 1994;74:882-894

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ARTICLES

Mapping the conversion of atrial flutter to atrial fibrillation and atrial fibrillation to atrial flutter. Insights into mechanisms

J Ortiz, S Niwano, H Abe, Y Rudy, NJ Johnson and AL Waldo
Department of Medicine, Case Western Reserve University, Cleveland, OH.

It is not generally believed that there is a relation between atrial flutter, thought to be due to a single reentrant circuit, and atrial fibrillation, thought to be due to simultaneously circulating multiple- reentrant wave fronts. However, there are many reasons to suggest that these rhythms are more closely related than previously thought. To test the hypothesis that the length of an area of functional block in the right atrial free wall is critical to the conversion of atrial flutter to atrial fibrillation and of atrial fibrillation to atrial flutter, we studied spontaneous and ATP-induced conversion of stable atrial flutter to sustained atrial fibrillation and spontaneous conversion of sustained atrial fibrillation to stable atrial flutter. We studied 13 episodes of the conversion of stable atrial flutter to sustained atrial fibrillation and sustained atrial fibrillation to stable atrial flutter in seven dogs with sterile pericarditis. Six episodes were spontaneous and seven were ATP related. All episodes were studied by using a multisite mapping system to record 190 unipolar electrograms (converted in the software to 95 bipolar electrograms) from the right atrial free wall along with ECG lead II. Atrial flutter induction was attempted by atrial stimulation (S1S2 or S1S2S3) or by rapid atrial pacing for > or = 20 beats from selected sites at selected rates. For both the spontaneous and the ATP-related episodes, stable atrial flutter was defined as any episode of > or = 5 minutes, and sustained atrial fibrillation was any episode of > or = 1 minute. During all the episodes of stable atrial flutter, a line of functional block with a mean length of 24 +/- 4 mm was localized on the right atrial free wall. When the previously stable line of functional block decreased to a mean of 16 +/- 3 mm (P < .05), either spontaneously or after ATP administration (40 mg i.v.), the new line of functional block was not long enough to maintain stable atrial flutter, and conversion to atrial fibrillation resulted. This shortened line of functional block continued to change and migrate over the right atrial free wall throughout sustained atrial fibrillation. These observations were similar for both spontaneous and ATP-induced conversions. When sustained atrial fibrillation evolved to stable atrial flutter, there was reformation of a long line of functional block, long enough (> or = prior length) to create a stable reentrant circuit, which then captured the right atrial free wall and subsequently both atria.(ABSTRACT TRUNCATED AT 400 WORDS)

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				V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society J. Am. Coll. Cardiol., August 15, 2006; 48(4): 854 - 906. [Full Text] [PDF]

				Authors/Task Force Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society Eur. Heart J., August 2, 2006; 27(16): 1979 - 2030. [Full Text] [PDF]

				Z. Qu Critical mass hypothesis revisited: role of dynamical wave stability in spontaneous termination of cardiac fibrillation Am J Physiol Heart Circ Physiol, January 1, 2006; 290(1): H255 - H263. [Abstract] [Full Text] [PDF]

				Y.-J. Lin, C.-T. Tai, T. Kao, H.-W. Tso, J.-L. Huang, S. Higa, Y. Yuniadi, B.-H. Huang, T.-Y. Liu, P.-C. Lee, et al. Electrophysiological Characteristics and Catheter Ablation in Patients With Paroxysmal Right Atrial Fibrillation Circulation, September 20, 2005; 112(12): 1692 - 1700. [Abstract] [Full Text] [PDF]

				O. F. Sharifov, V. V. Fedorov, G. G. Beloshapko, A. V. Glukhov, A. V. Yushmanova, and L. V. Rosenshtraukh Roles of adrenergic and cholinergic stimulation in spontaneous atrial fibrillation in dogs J. Am. Coll. Cardiol., February 4, 2004; 43(3): 483 - 490. [Abstract] [Full Text] [PDF]

				O. Wazni, N. F. Marrouche, D. O. Martin, A. M. Gillinov, W. Saliba, E. Saad, A. Klein, M. Bhargava, D. Bash, R. Schweikert, et al. Randomized Study Comparing Combined Pulmonary Vein-Left Atrial Junction Disconnection and Cavotricuspid Isthmus Ablation Versus Pulmonary Vein-Left Atrial Junction Disconnection Alone in Patients Presenting With Typical Atrial Flutter and Atrial Fibrillation Circulation, November 18, 2003; 108(20): 2479 - 2483. [Abstract] [Full Text] [PDF]

				P. Sanders, J. B. Morton, N. C. Davidson, S. J. Spence, J. K. Vohra, P. B. Sparks, and J. M. Kalman Electrical Remodeling of the Atria in Congestive Heart Failure: Electrophysiological and Electroanatomic Mapping in Humans Circulation, September 23, 2003; 108(12): 1461 - 1468. [Abstract] [Full Text] [PDF]

				G.C. Gronefeld and S.H. Hohnloser Quality of life in atrial fibrillation: an increasingly important issue Eur. Heart J. Suppl., September 1, 2003; 5(suppl_H): H25 - H33. [Abstract] [PDF]

				J. B. Morton, P. Sanders, J. K. Vohra, P. B. Sparks, J. G. Morgan, S. J. Spence, L. E. Grigg, and J. M. Kalman Effect of Chronic Right Atrial Stretch on Atrial Electrical Remodeling in Patients With an Atrial Septal Defect Circulation, April 8, 2003; 107(13): 1775 - 1782. [Abstract] [Full Text] [PDF]

				C.-T. Tai, J.-L. Huang, Y.-K. Lin, M.-H. Hsieh, P.-C. Lee, Y.-A. Ding, M.-S. Chang, and S.-A. Chen Noncontact three-dimensional mapping and ablation of upper loop re-entry originating in the right atrium J. Am. Coll. Cardiol., August 21, 2002; 40(4): 746 - 753. [Abstract] [Full Text] [PDF]

				O. Berenfeld, A. V. Zaitsev, S. F. Mironov, A. M. Pertsov, and J. Jalife Frequency-Dependent Breakdown of Wave Propagation Into Fibrillatory Conduction Across the Pectinate Muscle Network in the Isolated Sheep Right Atrium Circ. Res., June 14, 2002; 90(11): 1173 - 1180. [Abstract] [Full Text] [PDF]

				A. L. Waldo Mechanisms of atrial flutter and atrial fibrillation: distinct entities or two sides of a coin? Cardiovasc Res, May 1, 2002; 54(2): 217 - 229. [Full Text] [PDF]

				S. Nattel Therapeutic implications of atrial fibrillation mechanisms: can mechanistic insights be used to improve AF management? Cardiovasc Res, May 1, 2002; 54(2): 347 - 360. [Abstract] [Full Text] [PDF]

				J. B. Morton, M. J. Byrne, J. M. Power, J. Raman, and J. M. Kalman Electrical Remodeling of the Atrium in an Anatomic Model of Atrial Flutter: Relationship Between Substrate and Triggers for Conversion to Atrial Fibrillation Circulation, January 15, 2002; 105(2): 258 - 264. [Abstract] [Full Text] [PDF]

				P. D. Bella, A. Fraticelli, C. Tondo, S. Riva, G. Fassini, and C. Carbucicchio Atypical atrial flutter: clinical features, electrophysiological characteristics and response to radiofrequency catheter ablation Europace, January 1, 2002; 4(3): 241 - 253. [Abstract] [PDF]

				P. B. Sparks and J. M. Kalman Is atrial flutter a risk factor for stroke? J. Am. Coll. Cardiol., September 1, 2001; 38(3): 785 - 788. [Full Text] [PDF]

				C. W. Israel, J. R. Ehrlich, G. Gronefeld, A. Klesius, T. Lawo, B. Lemke, and S. H. Hohnloser Prevalence, characteristics and clinical implications of regular atrial tachyarrhythmias in patients with atrial fibrillation: insights from a study using a new implantable device J. Am. Coll. Cardiol., August 1, 2001; 38(2): 355 - 363. [Abstract] [Full Text] [PDF]

				R. Becker, A. Bauer, S. Metz, R. Kinscherf, J. C. Senges, K. D. Schreiner, F. Voss, W. Kuebler, and W. Schoels Intercaval Block in Normal Canine Hearts : Role of the Terminal Crest Circulation, May 22, 2001; 103(20): 2521 - 2526. [Abstract] [Full Text] [PDF]

				G. Stabile, A. De Simone, P. Turco, V. La Rocca, P. Nocerino, C. Astarita, F. Maresca, C. De Matteis, T. Di Napoli, E. Stabile, et al. Response to flecainide infusion predicts long-term success of hybrid pharmacologic and ablation therapy in patients with atrial fibrillation J. Am. Coll. Cardiol., May 1, 2001; 37(6): 1639 - 1644. [Abstract] [Full Text] [PDF]

				K. Matsuo, K. Uno, C. M. Khrestian, and A. L. Waldo Conduction left-to-right and right-to-left across the crista terminalis Am J Physiol Heart Circ Physiol, April 1, 2001; 280(4): H1683 - H1691. [Abstract] [Full Text] [PDF]

				Y. Tomita, K. Matsuo, J. Sahadevan, C. M. Khrestian, and A. L. Waldo Role of Functional Block Extension in Lesion-Related Atrial Flutter Circulation, February 20, 2001; 103(7): 1025 - 1030. [Abstract] [Full Text] [PDF]

				P. B. Sparks, S. Jayaprakash, J. K. Vohra, and J. M. Kalman Electrical Remodeling of the Atria Associated With Paroxysmal and Chronic Atrial Flutter Circulation, October 10, 2000; 102(15): 1807 - 1813. [Abstract] [Full Text] [PDF]

				K. Kumagai, K. Uno, C. Khrestian, and A. L. Waldo Single site radiofrequency catheter ablation of atrial fibrillation: studies guided by simultaneous multisite mapping in the canine sterile pericarditis model J. Am. Coll. Cardiol., September 1, 2000; 36(3): 917 - 923. [Abstract] [Full Text] [PDF]

				R.J Schilling, A.H Kadish, N.S Peters, J Goldberger, and D.W. Davies Endocardial mapping of atrial fibrillation in the human right atrium using a non-contact catheter Eur. Heart J., April 1, 2000; 21(7): 550 - 564. [Abstract] [PDF]

				B. Schumacher, W. Jung, H. Schmidt, C. Fischenbeck, T. Lewalter, A. Hagendorff, H. Omran, C. Wolpert, and B. Luderitz Transverse conduction capabilities of the crista terminalis in patients with atrial flutter and atrial fibrillation J. Am. Coll. Cardiol., August 1, 1999; 34(2): 363 - 373. [Abstract] [Full Text] [PDF]

				F. Anselme, N. Saoudi, H. Poty, R. Douillet, and A. Cribier Radiofrequency Catheter Ablation of Common Atrial Flutter : Significance of Palpitations and Quality-of-Life Evaluation in Patients With Proven Isthmus Block Circulation, February 2, 1999; 99(4): 534 - 540. [Abstract] [Full Text] [PDF]

				T.-J. Wu, M. Yashima, F. Xie, C. A. Athill, Y.-H. Kim, M. C. Fishbein, Z. Qu, A. Garfinkel, J. N. Weiss, H. S. Karagueuzian, et al. Role of Pectinate Muscle Bundles in the Generation and Maintenance of Intra-atrial Reentry : Potential Implications for the Mechanism of Conversion Between Atrial Fibrillation and Atrial Flutter Circ. Res., August 24, 1998; 83(4): 448 - 462. [Abstract] [Full Text] [PDF]