Nonpharmacologic treatment of common atrial flutter guided by transient entrainment

We attempted nonpharmacologic treatment for common atrial flutter in 7 patients, with direct current catheter ablation (CA) in 5 cases and cryoablation in 2 cases under the guidance of transient entrainment. Transient entrainment during common atrial flutter by pacing from the mid or low lateral right atrium (LLRA) revealed a long conduction time between the LLRA and the orifice of the coronary sinus (CSo) (73% to 121% of flutter cycle length). In 2 cases, fragmented electrograms were recorded at the low right atrial septum with durations of 150 msec and 155 msec, respectively. Because these fragmented electrograms were transiently entrained by rapid atrial pacing in the same manner as other atrial electrograms and were recorded in an area of long conduction, we believe that fragmented electrograms represent critical slow conduction. In 5 cases, CA was directed at this area. Three cases were successfully treated with 3 to 4 DC shocks of 100 J (follow up periods of 11.3, 4.5 and 3 months). Two cases which received 1 to 2 DC shocks of 100 J had recurrence of atrial flutter 6 and 4.7 months later, respectively. Two cases which showed atrial septal defect received surgical treatment. They were successfully treated with extended cryoablation in this same area (follow up periods of 26 and 9.2 months). In conclusion, extended ablation of an area of fragmented electrograms using transient entrainment may be an effective treatment for common atrial flutter.