Inter- and intraatrial dissociation during spontaneous atrial flutter: evidence for a focal origin of the arrhythmia

Programmed electrical stimulation of the heart was performed in 2 patients with spontaneous atrial flutter. Patient 1 was a young man with paroxysmal atrial flutter that had proved resistant to drug therapy and who was studied during an episode of sustained flutter. In this patient rapid atrial pacing from the coronary sinus at a critical rate faster than the intrinsic flutter rate provoked local atrial fibrillation in the mid and low right atrium which persisted after termination of pacing. In spite of persistent local fibrillation in these regions, atrial flutter continued in the left atrium and the high right atrium. A second burst of pacing resulted in restoration of sinus rhythm. Patient 2 was an elderly woman with probable sick sinus syndrome who developed spontaneous atrial flutter during the course of an electrophysiologic investigation. During flutter intracavitary recordings from multiple sites in the atria revealed a pattern of 3:2 Wenckebach conduction between the left atrium and the high right atrium, with block of every third atrial depolarization at the latter site. These results indicate that atrial flutter may exist at some sites in the atria which are functionally dissociated from the remainder of the atrial tissue, thus supporting the hypothesis that flutter in some patients may be focal in origin.