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Ann Thorac Surg 1997;64:548-552
© 1997 The Society of Thoracic Surgeons

Case Reports

Simultaneous Surgical Correction of a Common Atrium and Impure Flutter

Shigeo Yamauchi, MD, Hajime Imura, MD, Ryuzo Bessho, MD, Kenichi Yamada, MD, Shigeo Tanaka, MD

Second Department of Surgery, Nippon Medical School, Tokyo, Japan

Accepted for publication March 25, 1997.


   Abstract
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 Abstract
Introduction
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 References
 
We performed surgical correction and treatment of a common atrium and chronic impure flutter using a computerized mapping system in a 49-year-old man. A reentrant circuit was observed to exist around the left atrial appendage. In contrast to the regular activation in the left atrium, the activation sequence of the right atrium was extremely chaotic. Cryolesions were applied to the area of the reentrant pathway. After the operation, sinus rhythm was restored.


   Introduction
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 Introduction
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Atrial flutter is an atrial tachycardia with a regular rhythm that normally conducts to the ventricle in a 2:1 ratio. When a short cycle length atrial tachycardia, due to either circus movement or a focus, originates in the left atrium (LA), conduction is not always 1:1 to the right atrium (RA) during this arrhythmia, and is considered to be a form of impure flutter [1]. This type of reentrant arrhythmia can easily be confused with atrial fibrillation, because the ventricular response may be irregular with an electrocardiographic pattern identical to that seen in fibrillation. Differentiating such an arrhythmia potentially would be of clinical importance, as a single reentrant circuit might be amenable to catheter or surgical ablation.

A 49-year-old man with a common atrium, and severe mitral and tricuspid valve regurgitation, was admitted with chronic atrial fibrillation and a New York Heart Association functional class grade of III. The electrocardiogram exhibited atrial flutter-fibrillation (impure flutter), and the echocardiogram revealed a common atrium with an intact interventricular septum. We selected surgical intervention to treat the impure atrial flutter and common atrium with an atrioventricular valve cleft.

Before the institution of cardiopulmonary bypass, intraoperative atrial mapping was performed. A computerized 32-channel mapping system was used to analyze the atrial activation sequence of this arrhythmia [2].

The patient underwent a cleft repair of both the left and right atrioventricular valves. After the reconstruction of the septum, DeVega's tricuspid annuloplasty was performed, and the atrial septal defect was closed with an autologous patch.

Before reconstruction of the interatrial defect, cryolesions were applied to the area of the reentrant pathway. Cryolesions were applied around the left atrial appendage and longitudinally along the left superior and inferior pulmonary veins to ablate the reentrant circuit. Additional cryolesions were placed longitudinally along the right superior and inferior pulmonary veins and the isthmus between the tricuspid valve and the inferior vena cava to prevent recurrence of atrial arrhythmias.

A computer was used to store the digitalized unipolar data and display the waveforms. Regular and repetitive activation was observed in the LA, with the wavefront propagating around the left atrial appendage in a counterclockwise direction linked by a region of functional block with a cycle length of 160 milliseconds (Fig 1Go). In contrast to the regular and repetitive activation in the LA, the activation sequence of the RA was extremely chaotic (Fig 2Go). After weaning from cardiopulmonary bypass, spontaneous sinus rhythm was restored (Fig 3Go).



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  		Fig 1. . The 1,200-millisecond recordings from the left atrium showing organized atrial activity: 160-millisecond windows (A, B, C, and D) were consecutively analyzed, showing that the wavefront propagated around the left atrial appendage (LAA) in a counterclockwise direction with a cycle length of 160 milliseconds. Cryolesions were applied around the left atrial appendage and longitudinally along the left superior and inferior pulmonary veins.

 


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  		Fig 2. . Recordings from the right atrium showing disorganized atrial activity. The first electrogram is of surface lead II, and the following 30 electrograms are unipolar recordings from the right atrium.

 


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  		Fig 3. . (A) As the preoperative electrocardiogram shows, impure atrial flutter can easily be confused with atrial fibrillation, as the ventricular response is irregular and presents an electrocardiographic pattern identical to that seen in atrial fibrillation. (B) Postoperative electrocardiogram shows that regular sinus rhythm was restored after cryoablation.

 

   Comment
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References
 
The maze procedure has been used in patients undergoing surgical treatment for mitral valve disease or atrial septal defects, without first performing intraoperative atrial activation mapping [3, 4]. Activation mapping has repeatedly been used to better understand the mechanisms underlying atrial flutter and atrial fibrillation. Due to its complexity, atrial flutter has defined adequate description, much less definition of its mechanism. Questions that can be asked are, "When does an apparently irregular and chaotic signal propagation represent a chaotic source and when does it represent singular focal activation that, occurring at a high rate, results in complex dissociation of departing wavefronts?" and, "Does a single reentrant circuit giving rise to multiple wavelets always indicate that multiple reentrant circuits are present?"

The excitation due to circus movement and automatic foci in the LA does not demonstrate 1:1 conduction within the RA in a chaotic state [1]. Complex double wavefronts from both the current and preceding left atrial cycle co-exist in the RA [5]. This atrial discordance can be explained by the difference in the refractory periods of the two atria. The beat-to-beat wavefront propagation in the RA selectively moves to the area that has already recovered its excitability. This type of reentrant arrhythmia could easily be confused with atrial fibrillation, as the ventricular response can also be irregular and present an electrocardiographic pattern identical to that seen in atrial fibrillation. In our case, a single stable reentrant circuit produced this arrhythmia. A minor degree of dissociation was also noted in the LA. The electrocardiographic pattern of the ventricular response may not be useful, because it is often irregular and can be mistaken for that of atrial fibrillation even when it is impure flutter. This mistaken diagnosis may lead the surgeon to perform the maze procedure when only cryoablation of the reentrant circuit is needed. In this report, sinus rhythm was restored after cryoablation of the area in which we observed regular and repetitive activation in the LA, thus eliminating the need for the maze procedure.

In conclusion, although a single intraoperative atrial activation mapping does not represent multiple reentrant circuits, inference can be made to draw the whole process. Therefore the maze procedure should not be blindly performed without first performing an electrophysiologic study. Atrial flutter can be properly treated with operation or catheter ablation only when the activation sequence has been clearly elucidated before the procedure.


   Footnotes
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 Introduction
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 References
 
Address reprint requests to Dr Yamauchi, Second Department of Surgery, Nippon Medical School, 1-1-5, Sendagi Bunkyo-ku Tokyo 113, Japan.


   References
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 Footnotes
 Abstract
 Introduction
 Comment
 References
 

  1. Yamauchi S, Sato S, Schuessler RB, Boineau JP, Matsunaga Y, Cox JL. Induced atrial arrhythmia in a canine model of left atrial enlargement [Abstract]. PACE 1990;13:556.
  2. Harada A, Sasaki K, Fukushima T, et al. Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease. Ann Thorac Surg 1996;61:104–12.[Abstract/Free Full Text]
  3. Cox JL, Schuessler RB, Agostino HJ, et al. The surgical treatment of atrial fibrillation: III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 1991;101:569–83.[Abstract]
  4. Bonchek LI, Burlingame MW, Worley SJ, et al. Cox/maze procedure for atrial septal defect with atrial fibrillation: management strategies. Ann Thorac Surg 1993;55:607–10.[Abstract/Free Full Text]
  5. Schuessler RB, Boineau JP, Bromberg BI, Hand DE, Yamauchi S, Cox JL. Normal and abnormal activation of the atrium. In: Zipes DP, Jalife J, eds. Cardiac electrophysiology. From cell to bedside. 2nd ed. Philadelphia: Saunders, 1995:543–62.



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