[Non-drug treatment of atrial flutter]

Atrial flutter is a relatively rare type of cardiac arrhythmia. The clinical tolerability of such attacks may be poor and the efficacy of antiarrhythmic drugs is limited, both in terminating the flutter and in preventing its recurrence. Non-drug treatment is particularly important in this domain. Stopping the flutter is now given top priority and is achieved by rapid atrial stimulation, which is usually delivered by the trans-oesophageal route. This results in restoration of sinus rhythm in between 60 and 90% of cases. External electrical shocks are used only in forms involving poor hemodynamic safety or if the transesophageal approach has failed. It is nearly always successful with low energy levels of 50 to 100 J. Several options can be considered for the etiological treatment. One is the implantation of an anti-tachycardic pacemaker, which is based on the principle of interrupting the flutter by rapid atrial stimulation, the treatment being triggered either manually or automatically. The outcome is disappointing. In disorders of the atrium, atrial flutter can be abolished by suppressing the episodes of bradycardia. Electrical interruption of the bundle of His by catheterization is indicated for the treatment of severe, refractory forms. It is combined with the insertion of a cardiac stimulator, generally VVIR. The functional improvement obtained is remarkable. It has also been suggested that flutter can be dealt with by a direct approach to the right atrium by means of either surgery or catheterization. Experience with endocardial treatment by a radiofrequency current is still limited, but initial results are encouraging.