Atrial Flutter.

Atrial flutter (AFl) is an arrhythmia resulting from reentry in a macroreentrant circuit, most commonly in the right atrium. Typical AFl uses the narrow isthmus of right atrial tissue between the tricuspid valve annulus and the inferior vena cava orifice as part of the macroreentrant circuit. The treatment of AFl is directed toward achieving the following four goals. 1) In the presence of AFl, adequate rate control is required, which can be achieved in most but not all patients by oral or intravenous digoxin, calcium channel blockers, or beta-blockers, alone or in combination. 2) Anticoagulation with warfarin should be considered in patients with recurrent AFl, especially those over 70 years of age, and those with a history of atrial fibrillation, stroke, or structural heart disease. 3) Conversion to sinus rhythm can be achieved in up to 70% of patients with intravenous ibutilide, but this should be reserved for patients with either normal hearts or only mild left ventricular dysfunction. Direct-current cardioversion is nearly 100% effective and is ideal for patients with left ventricular dysfunction. 4) Long-term maintenance of sinus rhythm may be achieved in up to 50% to 60% of patients by using antiarrhythmic drugs, including sotalol, amiodarone, dofetilide, propafenone, and flecainide, but with the potential for causing significant proarrhythmia and side effects. Radiofrequency catheter ablation may cure over 90% of patients with type 1 AFl (using the tricuspid valve to inferior vena cava isthmus), and from 70% to 90% of patients with atypical AFl. Newer mapping techniques, such as electroanatomic mapping, are likely to further reduce procedure time and improve success rates.