Date Released: November 23, 2009

Term of Approval: Noevember 23, 2012

Program Summary

Dr. Melvin Scheinman has provided an excellent review of atypical flutter circuits. He began with a review of the 12 lead EKG and physiology of isthmus dependent flutter. He discussed the site of the barrier to conduction in isthmus dependent flutter. Double wave reentry was described initially by Brugada and Wellens in the ventricle and then described by Scheinman, et al. for atrial flutter.

Double wave reentry is typically caused by insertion of a PAC with a sudden change in tachycardia cycle length. The physiology of lower loop reentry was then discussed as well. Lower loop physiology may also give rise to confusion as to whether bi-directional block is present because of shunting around the posterior wall. Thus, to optimally test for block in these patients the halo catheter should be advanced across the isthmus to test for block. Inter-isthmus reentry was discussed and mapping the medical side of the isthmus was recommended to look for continuous electrograms that may span 50% or more of the tachycardia cycle length. Left atrial flutters were addressed, and they most commonly occur around veins or the mitral isthmus.

Additionally, when left atrial flutters occur after atrial fibrillation ablation, they can occur around scar caused by the previous ablation procedure.

Target Audience

This program is intended for a professional audience.

• Cardiac electrophysiologists
• Cardiology and cardiac electrophysiology fellows
• Cardiac surgeons
• Other cardiologists and radiologists

Learning Objectives

Upon completion of this educational activity, participants will be able to:

• How to recognize and differentiate typical isthmus dependent flutter from atypical flutter.
  
• How to appropriately analyze the 12 lead EKG of isthmus dependent flutter.
  
• Recognize the types of atypical flutter and where they can be ablated.
  
• How to avoid unnecessary ablation due to shunting of the wavefront through the crista.
  

Faculty

Melvin M. Scheinman, MD, FHRS
University of California-San Francisco
San Francisco, CA

Author

Kenneth A. Ellenbogen, MD, FHRS
Virginia Commonwealth University Medical Center
Richmond, VA

Accreditation

The Heart Rhythm Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Continuing Medical Education (CME)

The Heart Rhythm Society designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The AMA has determined that physicians not licensed in the USA who participate in this CME activity are eligible for AMA PRA Category 1 Credits^TM.

Continuing Education (CE) for Nurses

The Heart Rhythm Society is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

It has been assigned code 7M7R3X-PRV-09-04.

A maximum of 1.0 credit hours are available for this educational activity.

View Webcast

EP Fellows Bootcamp: Atypical Flutters

Required Hardware and Software 

• Computer Screen with USB Drive Screen resolution of 1024x786 or larger
  
• Sound card and speakers/headphones
  
• Operating System Requirement: Windows Vista; Windows XP Service Pack 2, Windows 7 Intel® Pentium® III 450MHz or faster processor (or equivalent) 128MB or RAM Mac OS Apple Mac OS X 10.4.8 or above Intel Core TM Duo 1.83GHz or faster processor 128MB of RAM Plug-in
  

Supported by an educational grant from: