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Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report

INTRODUCTION: Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challe...

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Autores principales: Fuher, Alexandra Nicole, Borne, Ryan, Cunningham, John
Formato: Online Artículo Texto
Lenguaje:English
Publicado: University of California Irvine, Department of Emergency Medicine publishing Western Journal of Emergency Medicine 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10247180/
https://www.ncbi.nlm.nih.gov/pubmed/37285502
http://dx.doi.org/10.5811/cpcem.1413
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author Fuher, Alexandra Nicole
Borne, Ryan
Cunningham, John
author_facet Fuher, Alexandra Nicole
Borne, Ryan
Cunningham, John
author_sort Fuher, Alexandra Nicole
collection PubMed
description INTRODUCTION: Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology. CASE REPORT: A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient’s ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads (absent precordial transition). This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered. CONCLUSION: Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available.
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spelling pubmed-102471802023-06-08 Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report Fuher, Alexandra Nicole Borne, Ryan Cunningham, John Clin Pract Cases Emerg Med Case Report INTRODUCTION: Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology. CASE REPORT: A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient’s ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads (absent precordial transition). This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered. CONCLUSION: Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available. University of California Irvine, Department of Emergency Medicine publishing Western Journal of Emergency Medicine 2023-05-30 /pmc/articles/PMC10247180/ /pubmed/37285502 http://dx.doi.org/10.5811/cpcem.1413 Text en © 2023 Fuher et al https://creativecommons.org/licenses/by/4.0/This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/)
spellingShingle Case Report
Fuher, Alexandra Nicole
Borne, Ryan
Cunningham, John
Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
title Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
title_full Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
title_fullStr Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
title_full_unstemmed Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
title_short Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
title_sort diagnosing atypical flutter in the post-atrial fibrillation ablation patient: a case report
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10247180/
https://www.ncbi.nlm.nih.gov/pubmed/37285502
http://dx.doi.org/10.5811/cpcem.1413
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