The mystery of the missing P waves: a case report
Yuanguo Chen1, Haibo Zhang2, Changli Han3
1Department of Cardiovascular Medicine, Ya'an People's Hospital, Ya'an, Sichuan, People's Republic of China. 283767641@qq.com.
Journal of Medical Case Reports
|April 11, 2025
Summary
Diagnosing atrial flutter with hidden activity requires electrophysiological study, especially in structural heart disease. This avoids unnecessary pacemakers and restores normal heart rhythm.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Surgery
Background:
- Atrial flutter with concealed activity presents diagnostic challenges on surface ECGs.
- Structural heart disease can complicate arrhythmia diagnosis and management.
- This case involves a patient with rheumatic mitral stenosis and a prior maze procedure.
Purpose of the Study:
- To highlight the diagnostic difficulties of concealed atrial flutter.
- To emphasize the role of electrophysiological study in avoiding unnecessary pacemaker implantation.
- To present a rare case of atrial flutter with absent surface atrial activity.
Main Methods:
- A 60-year-old woman with mitral stenosis and prior maze procedure presented with bradycardia.
- Surface ECGs and echocardiography showed no P waves and atrial mechanical silence.
- Electrophysiological study identified cavotricuspid isthmus-dependent atrial flutter with extensive right atrial low-voltage zones.
Main Results:
- Electrophysiological study revealed concealed atrial flutter masked by severe atrial fibrosis.
- Radiofrequency ablation successfully created bidirectional isthmus block.
- Sinus rhythm was restored without the need for a pacemaker.
Conclusions:
- Electrophysiological study is crucial for diagnosing obscured atrial flutter in bradycardia with electromechanical dissociation.
- This diagnostic approach prevents inappropriate pacemaker implantation in patients with structural heart disease.
- Successful ablation restored physiological rhythm, offering a management paradigm for complex arrhythmias.
Keywords:
Atrial flutterCase reportCatheter ablationElectrophysiological study (EPS)Radiofrequency ablationRheumatic heart diseaseMore Related Videos
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