A atrial flutter consisted of two different conduction pathways

Area of Science:

• Cardiology
• Electrophysiology
• Medical Devices

Background:

• A 64-year-old male with a history of sick sinus syndrome and DDD-pacemaker implantation presented with refractory atrial flutter (AFL).
• Standard pharmacological treatment with verapamil proved ineffective in managing the patient's symptomatic AFL.

Observation:

• Electrophysiological study identified a common type of AFL (AFL1) triggered by atrial burst pacing.
• Following successful radiofrequency (RF) ablation of AFL1, a second distinct AFL (AFL2) with a different atrial rate was detected.

Findings:

• Isthmus RF ablation successfully eliminated AFL1.
• A subsequent ablation procedure using standard catheterization techniques effectively treated AFL2.
• The findings suggest the presence of two distinct atrial flutter pathways with differing conduction properties.

Implications:

• This case highlights the potential for multiple, distinct atrial flutter circuits in patients with underlying cardiac conditions and pacemakers.
• Successful catheter ablation of complex AFL, even in the presence of a pacemaker, offers a curative treatment option.
• Understanding and targeting multiple AFL pathways is crucial for achieving long-term rhythm control and symptom resolution.