Characterization of the excitable gap in human type I atrial flutter

Typical Atrial Flutter Mapping and Ablation

Isthmus-dependent flutter represents a defeated arrhythmia. Possibly one of the most outstanding successes in terms of understanding the mechanism behind it has led to an effective, relatively simple, and safe targeted therapy. Technology, fulfilling a number of the clinical electrophysiologist's dreams, has linked diagnosis and therapy in computerized systems showing real-time imagines of the right atrium, the arrhythmia circuit, and the ablation target. The entire history of clinical electrophysiology is contained in its path and atrial flutter needs to be regarded with immense respect for a large amount of knowledge that its study always engenders."

Variations in duration and composition of the excitable gap around the tricuspid annulus during typical atrial flutter

BACKGROUND

Differences in the duration of the excitable gap along the reentry circuit during typical atrial flutter are poorly known.

AIM

To prospectively evaluate and compare the duration and composition of the excitable gap during typical counterclockwise atrial flutter in different parts of the circuit all around the tricuspid annulus.

METHODS

The excitable gap was determined by introducing a premature stimulus at various sites around the tricuspid annulus during typical counterclockwise atrial flutter in 34 patients. Excitable gap was calculated as the difference between the longest resetting coupling interval and the effective atrial refractory period.

RESULTS

The duration of the excitable gap, the effective atrial refractory period and the resetting coupling interval differed significantly along the tricuspid annulus. Duration of excitable gap was significantly longer at the low lateral right atrium (79±22 ms) than at the cavotricuspid isthmus (66±23 ms; P=0.002). The effective atrial refractory period was significantly longer at the cavotricuspid isthmus (160±26 ms) than at the high lateral right atrium (149±29 ms; P=0.004). Other locations, such as coronary sinus ostium, right atrial septum and atrial roof displayed intermediate values.

CONCLUSION

The duration of the excitable gap differed significantly along the tricuspid annulus, with a larger excitable gap at the lateral right atrium and a shorter excitable gap at the cavotricuspid isthmus, because of longer refractory periods at the isthmus.

Electrophysiological mechanisms of atrial flutter

Atrial flutter (AFL) is a common arrhythmia in clinical practice. Several experimental models, such as tricuspid regurgitation model, tricuspid ring model, sterile pericarditis model and atrial crush injury model, have provided important information about reentrant circuit and can test the effects of antiarrhythmic drugs. Human AFL has typical and atypical forms. Typical AFL rotates around the tricuspid annulus and uses the crista terminalis and sometimes sinus venosa as the boundary. The tricuspid isthmus is a slow conduction zone and the target of radiofrequency ablation. Atypical AFL may arise from the right or left atrium. Right AFL includes upper loop reentry, free wall reentry and figure-of-8 reentry. Left AFL includes mitral annular AFL, pulmonary vein-related AFL and left septal AFL. Radiofrequency ablation of the isthmus between the boundaries can eliminate these arrhythmias.

Effect of chronic amiodarone therapy on excitable gap during typical human atrial flutter

INTRODUCTION

Class I antiarrhythmic drugs increase duration of the excitable gap (EG) during typical atrial flutter whereas intravenous class III drugs decrease the EG. The effect of chronic oral amiodarone therapy on the EG is unknown.

METHODS AND RESULTS

EG was prospectively determined by introducing a premature stimulus and analyzing the response pattern during typical atrial flutter in 30 patients without antiarrhythmic drugs and in 20 patients under chronic oral amiodarone therapy. EG was calculated by the difference between the longest coupling interval leading to resetting and the effective atrial refractory period (EARP). A fully EG was defined by the portion of EG where the response curve of the return cycles was flat. A partially EG was defined by the portion of EG where the return cycle increases while coupling interval decreases. A resetting response curve was constructed by plotting the duration of the return cycle against the value of the coupling interval. Cycle length (CL; 222 +/- 17 vs 267 +/- 20 msec, P < 0.0001), EARP (128 +/- 16 vs 152 +/- 18 msec, P < 0.0001), and EG (54 +/- 19 vs 70 +/- 21 msec, P = 0.01) were significantly longer in patients taking amiodarone than in controls. Compared to CL, the relative part of the EARP (57 +/- 7 vs 57 +/- 6%, P = 0.96) and EG (24 +/- 7 vs 26 +/- 8%, P = 0.41) were comparable in both groups. The fully EG was larger in patients under chronic amiodarone therapy than in controls (39 +/- 21 vs 26 +/- 20 msec, P = 0.03). Neither duration of the partially EG (28 +/- 15 vs 31 +/- 15 msec, P = 0.42) nor slope of the ascending portion of the resetting response curve (1.15 +/- 0.5 vs 1.13 +/- 0.4 msec/msec, P = 0.71) differed between the two groups.

CONCLUSION

EG in patients under chronic amiodarone therapy is significantly larger than in controls, mainly because of a longer fully EG. This observation may be explained by opposite effects on conduction velocity and refractoriness.

Predicting the entrainment of reentrant cardiac waves using phase resetting curves

Excitable media, such as the Belousov-Zhabotinsky medium or the heart, are capable of supporting excitation waves that circulate in a closed repetitive path--a phenomenon known as reentrant excitation. A single stimulus, depending on its magnitude, timing, and location, can cause a time shift of the reentrant excitation called resetting. The present study examines the ability of resetting data to predict the effects of periodic stimuli on reentrant excitation circulating on an annular domain. We compare the results of the theoretical models with experiments carried out in an animal model of a dangerous reentrant cardiac rhythm. The current work may lead to improved approaches to therapy through a better understanding of how typical clinical stimuli interact with abnormal reentrant cardiac rhythms.

Influence of propafenone on resetting and termination of canine atrial flutter

Previous studies on atrial flutter (AF) presumed that resetting was due to the prematurity effect (PE) in which the stimulated antegrade wavefront travels in the tail of the AF preexisting wavefront. We studied the collision effect (CE) between the AF and the stimulated retrograde wavefronts, its contribution to resetting, and its relationship to AF termination and how they are affected by the Class IC agent propafenone (PPF). A canine model of AF was created using a Y-shaped lesion in the right atrium in 14 dogs (33 +/- 3 kg). Five atrial bipolar electrodes were positioned around the tricuspid valve. In a subsequent set of 11 dogs, we used 16 bipolar electrodes for recording. AF was induced by burst pacing. Single and multiple stimuli were applied to measure conduction time and reset-response curves (RRCs). This was repeated after the administration of PPF (1 mg/kg loading dose for 10 minutes, followed by 1.8 mg/kg/per hour infusion). Three distinct mechanisms were found to contribute to the RRC: the PE, the CE, and heterogeneity. PPF stabilized the RRC, increased significantly the cycle length (CL), the duration of the effective refractory period, as well as the duration of the excitable gap. However, PPF did not alter the duration of the fully excitable portion. We studied 36 annihilations without and 48 with PPF. Transient fibrillation was found in 75% of the episodes without, compared to 22% with PPF. Other types of termination such as conduction block, CL oscillations, and reversal of activation were found for 25% of the episodes without and 78% with PPF. In many cases, conduction block and CL oscillations were associated with a failure of propagation of the stimulated antegrade wavefront in the region of collision. Termination by reversal of activation suggests that propagation was two dimensional and could not be represented by a one dimensional movement. The average coupling interval (in percent of CL), that induced fibrillation was not significantly different from that at which conduction block occurred. This suggests that transient fibrillation is associated with a weak CE rather than with rapid pacing. The CE is amplified by multiple stimuli and PPF. The incidence of transient fibrillation in AF annihilation diminishes with PPF as the CE becomes more important. This suggests that the evaluation of PE and CE in AF may be an indication of the risk of atrial fibrillation.