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Rythmopole

Atrial flutter

Atrial flutter is an organized heart rhythm disorder characterized by a regular electrical circuit rotating at high frequency within the right atrium. This rhythm condition, closely related to but more regular than atrial fibrillation, requires specialized management by a cardiac electrophysiologist.

Atrial flutter is a heart rhythm disorder characterized by abnormal yet organized electrical activity within the atria, primarily the right atrium. Unlike atrial fibrillation, where the electrical activity is completely chaotic, atrial flutter presents with a highly regular electrical circuit, looping around at a frequency of approximately 250 to 350 beats per minute (typically around 300 beats per minute).

This regularity makes atrial flutter a distinct and well-organized arrhythmia, which results in specific diagnostic and therapeutic characteristics.

Fortunately, the atrioventricular (AV) node — the heart’s natural electrical connection between the atria and the ventricles — acts as a filter, allowing only a portion of these rapid electrical impulses from the atria to reach the ventricles. As a result, the ventricles generally beat at 150 beats per minute or less (with one out of every two, three, or four impulses being transmitted).

Types of Atrial Flutter

There are two main types of atrial flutter:

Typical (or common) atrial flutter:
The electrical circuit rotates around the tricuspid valve in the right atrium and passes through a specific anatomical area called the cavotricuspid isthmus. This is the most common form (about 80% of cases) and is generally the most amenable to treatment with catheter ablation.

Atypical atrial flutter:
The electrical circuit follows other pathways, often located in the left atrium or in scarred areas of heart tissue. These forms can be more complex to treat.

Atrial flutter can present in different patterns:

  • Paroxysmal: Occurs in episodes that stop spontaneously;
  • Persistent: Requires medical intervention to restore normal rhythm;
  • Permanent: The arrhythmia is continuously present despite attempts at cardioversion.

Atrial flutter can occur in an otherwise healthy heart, but it is more commonly associated with certain cardiac conditions or risk factors:

Cardiac Factors:

  • Atrial enlargement: Enlargement of the atrial chambers, regardless of the cause, promotes the formation of re-entry circuits;
  • Structural heart disease:
  • Ischemic heart disease (coronary artery disease);
  • Valvular disease, particularly affecting the mitral or tricuspid valves;
  • Cardiomyopathies (hypertrophic or dilated);
  • Congenital heart disease, especially after corrective surgery;
  • Constrictive pericarditis.
  • Post-cardiac surgery scars: Surgical scarring, especially in the atria, can create a substrate for flutter development;
  • History of atrial fibrillation: These two arrhythmias are often associated and may perpetuate each other.

Non-Cardiac Factors:

  • Advanced age: The incidence of atrial flutter increases with age;
  • High blood pressure (hypertension);
  • Chronic lung disease: COPD, pulmonary embolism;
  • Hyperthyroidism;
  • Sleep apnea;
  • Excessive alcohol consumption;
  • Electrolyte imbalances;
  • Obesity.

In some cases, atrial flutter may appear transiently following electrical or drug cardioversion for atrial fibrillation, or after incomplete atrial fibrillation ablation.

How Does Atrial Flutter Present?

The clinical manifestations of atrial flutter vary from person to person and depend largely on the ventricular rate (the number of impulses transmitted to the ventricles) and the presence of any underlying heart disease.

Common Symptoms:

  • Palpitations: a sensation of rapid and regular heartbeats;
  • Shortness of breath (dyspnea), either with exertion or at rest;
  • Unusual fatigue;
  • Reduced exercise tolerance;
  • Chest tightness or discomfort;
  • Lightheadedness or dizziness;
  • Fainting spells (syncope) — less common.

Asymptomatic Forms:
It is important to note that a significant number of patients (approximately 20–30%) experience no symptoms. In such cases, atrial flutter is often discovered incidentally during a routine electrocardiogram (ECG) or during tests performed for another reason.

Potential Complications:

If left untreated, atrial flutter can lead to several complications:

  • Heart failure: A rapid and sustained ventricular rate can weaken the heart muscle, leading to or worsening heart failure;
  • Thromboembolic complications: Similar to atrial fibrillation, atrial flutter is associated with an increased risk of blood clot formation in the atria, which can lead to embolisms, particularly strokes (cerebral embolisms);
  • Tachycardiomyopathy: Impaired ventricular function caused by a persistently rapid heart rate;
  • Progression to atrial fibrillation: Atrial flutter and atrial fibrillation often share the same risk factors and can coexist or evolve from one to the other.

The stroke risk associated with atrial flutter is considered comparable to that of atrial fibrillation, and an individual assessment of thromboembolic risk is essential to determine the need for anticoagulant therapy.

How Is Atrial Flutter Diagnosed?

Electrocardiogram (ECG):
The diagnosis of atrial flutter is primarily based on a standard 12-lead electrocardiogram (ECG), which reveals characteristic features:

  • Flutter waves (F waves): Regular sawtooth-shaped atrial activity, particularly visible in the inferior leads (II, III, aVF) and V1, at a frequency of approximately 250–350 beats per minute;
  • Variable atrioventricular (AV) block: Transmission of every second (2:1 block), third (3:1 block), or fourth atrial impulse, resulting in a regular ventricular rate of around 150, 100, or 75 beats per minute;
  • Generally normal QRS complexes, unless there is a conduction abnormality or underlying heart disease.

In cases of fixed 2:1 block (the most common), flutter waves can be difficult to visualize, and specific maneuvers may be necessary to confirm the diagnosis, such as carotid sinus massage (performed only by a physician), which can temporarily increase the degree of AV block and reveal the flutter waves.

Additional Tests:

Other tests may be required to confirm the diagnosis, assess underlying causes, or plan treatment:

  • Holter ECG: Continuous heart rhythm monitoring for 24 to 48 hours, useful for detecting paroxysmal flutter or assessing average ventricular rate;
  • Transthoracic echocardiography: To evaluate cardiac structure and function, detect underlying heart disease, and measure atrial size;
  • Transesophageal echocardiography: Sometimes necessary before cardioversion to rule out the presence of blood clots in the left atrium;
  • Electrophysiological study: Performed during catheter ablation, this allows precise characterization of the flutter circuit and confirmation of its mechanism.

Blood tests (electrolyte panel, thyroid function, etc.) are also performed to identify contributing factors.

These tests are available at the various Rythmopôle Paris centers, including Cardiopôle Yvart (15th arrondissement) and Centre Damrémont (18th arrondissement).

The management of atrial flutter is based on several complementary objectives:

Prevention of Thromboembolic Complications

As with atrial fibrillation, atrial flutter increases the risk of blood clot formation and stroke. Anticoagulant therapy is therefore often necessary:

  • Direct oral anticoagulants (DOACs): apixaban, rivaroxaban, dabigatran, edoxaban;
  • Vitamin K antagonists: warfarin, fluindione.

The decision to initiate anticoagulation is based on an individual assessment of thromboembolic risk, typically using the CHA₂DS₂-VASc score.

Anticoagulation is usually recommended before any electrical or drug cardioversion if the flutter has lasted more than 48 hours or if its duration is unknown.

Heart Rate Control

Medications that slow the heart rate help limit the ventricular rate and relieve symptoms, without necessarily restoring a normal sinus rhythm:

  • Beta-blockers (metoprolol, bisoprolol, etc.);
  • Rate-limiting calcium channel blockers (diltiazem, verapamil);
  • Digoxin (generally used in combination with other drugs).

Restoring Sinus Rhythm

Several approaches can be used to attempt to restore normal sinus rhythm:

  • External electrical cardioversion: A synchronized electric shock delivered under short sedation, with a very high immediate success rate (>90%). However, this procedure does not treat the underlying cause of the flutter and does not prevent recurrences.
  • Pharmacological cardioversion: Antiarrhythmic drugs (flecainide, propafenone, amiodarone, etc.) are used to attempt to restore sinus rhythm. This approach is generally less effective for atrial flutter compared to electrical cardioversion.

Prevention of Recurrences

Antiarrhythmic medications may be prescribed to reduce the risk of recurrence, but their effectiveness is limited in atrial flutter:

  • Class Ic antiarrhythmics: flecainide, propafenone;
  • Class III antiarrhythmics: amiodarone, sotalol.

These drugs are generally less effective in preventing flutter recurrences than catheter ablation.

Curative Treatment: Catheter Ablation

Catheter ablation is considered the gold standard treatment for typical atrial flutter, offering definitive resolution in the vast majority of cases:

  • Principle: Creation of a conduction block line at the cavotricuspid isthmus to interrupt the flutter circuit;
  • Technique: Catheters are introduced via the femoral vein to the heart under local anesthesia, and radiofrequency energy is applied to create linear lesions;
  • Effectiveness: Success rates exceed 90% for typical atrial flutter, with a low recurrence rate;
  • Practical details: The procedure is performed on an outpatient basis (admission in the morning, discharge the same day);
  • Indications: Recommended as first-line treatment for symptomatic typical atrial flutter, especially in cases of recurrence after cardioversion.

This procedure is performed at the Institut Mutualiste Montsouris by the rhythmologists at Rythmopôle Paris.

It is important to note that even after successful ablation of atrial flutter, persistent risk factors may promote the development of other atrial arrhythmias, particularly atrial fibrillation. Regular follow-up with a cardiac electrophysiologist remains essential.

After Ablation

Follow-up after successful atrial flutter ablation includes:

  • A follow-up consultation with an ECG at 1 to 3 months;
  • Temporary continuation of anticoagulant therapy, usually for at least 1 to 3 months after the procedure, followed by reassessment based on the CHA₂DS₂-VASc score;
  • Possible temporary continuation of rate-control medications, which can be gradually reduced and discontinued if sinus rhythm is maintained;
  • Regular monitoring to detect possible recurrences or the onset of atrial fibrillation.

Lifestyle Modifications

Regardless of the chosen treatment strategy, general lifestyle measures are recommended to reduce the risk of recurrence and improve overall cardiovascular health:

  • Control of cardiovascular risk factors (high blood pressure, diabetes, dyslipidemia);
  • Maintaining a healthy weight, with weight loss if necessary;
  • Regular, adapted physical activity;
  • Limiting alcohol consumption;
  • Smoking cessation;
  • Stress management;
  • Treatment of sleep apnea if present.

These measures help not only to reduce the risk of atrial flutter recurrence but also to prevent the development of other arrhythmias and to improve overall cardiovascular health.

Rythmopôle Paris offers comprehensive expertise in the management of atrial flutter:

  • A team of experienced rhythm specialists dedicated to the diagnosis and treatment of heart rhythm disorders;
  • An advanced technical platform at the Institut Mutualiste Montsouris, enabling high-precision ablation procedures;
  • Extensive experience in atrial flutter ablation, with optimal success rates;
  • Primarily outpatient management, allowing for a quick return home and to normal activities;
  • Personalized follow-up tailored to each patient;
  • A holistic approach that includes the prevention of thromboembolic complications, risk factor control, and long-term monitoring.
**Atrial flutter is an organized heart rhythm disorder that, although generally less chaotic than atrial fibrillation, shares certain risks with it, notably the risk of stroke.** Its diagnosis is primarily based on an electrocardiogram, which reveals the characteristic “sawtooth” atrial activity. Anticoagulant therapy is often necessary to prevent thromboembolic complications, while **catheter ablation is now considered the gold standard treatment for typical atrial flutter**, offering a definitive cure in over 90% of cases. Patients experiencing regular palpitations or those already diagnosed with atrial flutter will benefit from a specialized evaluation at **Rythmopôle Paris**, where our team of rhythm specialists provides personalized and optimal care.

Questions fréquentes

Consultation spécialisée pour un flutter atrial avec un rythmologue – analyse des symptômes, diagnostic électrocardiographique et traitement ciblé

Heart Rhythm Disorders: Diagnosis and Treatment Options

Atrial flutter may present with rapid, regular palpitations, shortness of breath during exertion, or unusual fatigue. This heart rhythm disorder requires a precise evaluation to determine its form and to prevent potential complications.
The rhythm specialists at Rythmopôle perform a comprehensive assessment and offer personalized treatment options, ranging from medication to modern ablation techniques, to restore a normal heart rhythm and improve your quality of life.

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