A 3.5 mm tip Thermo Cool Surround Flow bidirectional F-J curve catheter (Biosense Webster Inc., Diamond Bar, CA, USA) was placed into the LA. Systemic anticoagulation with heparin was given in order to maintain an activated clotting time >300 seconds. Transseptal access to the left atrium (LA) was then established from the right femoral vein under fluoroscopic guidance using contrast injection to visualize the fossa ovalis and the left atrial cavity. The CS activation sequence was distal to proximal, compatible with an atypical LAF and the cycle length was 260 msec ( Figure 2). A 6 Fr decapolar deflectable catheter was advanced into the right atrium and placed into the coronary sinus (CS). Venous access was obtained twice through the right femoral vein. 12-lead ECG showed flutter waves morphology positive in V1, flat in lead I, and negative in lead II, III, Avf ( Figure 1). The patient was brought to the electrophysiology lab in atrial flutter. Procedure was performed in fasting state and under conscious sedation. He was scheduled for atrial flutter ablation after transesophageal echocardiogram. He received oral anticoagulation therapy and rate control treatment with metoprolol was started waiting for catheter ablation. The patient complained for mild swelling of his ankles and worsening shortness of breath on exertion. Three years after surgery, he developed symptomatic rapid atrial flutter. At the time of his valve surgery, the left atrial appendage was removed and a simplified Cox-MazeIII procedure (PV encircling and connecting lines) was also performed. He also had history of paroxysmal atrial fibrillation. Previous cardiac history includes myxomatous mitral valve, severe prolapse with flail of the mitral posterior leaflet with severe mitral valve regurgitation requiring mitral valve repair at age 69. One aspect that derives from the widespread diffusion of ablation procedures for atrial fibrillation, both percutaneous and surgical, is the onset of LAF linked to the presence of a gap at the pulmonary vein (PV) ostia or antra.Ī 72-year-old man presented at our Centre for an elective atrial flutter ablation procedure. Left atrial flutter (LAF) most commonly involves reentry around a scar from prior cardiovascular surgery, catheter ablation, or congenital heart disease. Considering that atypical atrial flutter reentry circuit may involve various locations in both atria, activation mapping of the flutter circuit is important to confirm that catheter ablation is being performed at an isthmus involved in the circuit. Atypical atrial flutter is a regular arrhythmia characterized by a non-cavotricuspid isthmus dependent macro-reentry.
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