Radiofrequency ablation of atrial flutter.

Activation mapping in common atrial flutter has shown circular (reentrant) activation of the right atrium around anatomic structures and areas of functional block. The direction of rotation is counterclockwise (in a frontal view), and in the low right atrium the myocardium between the inferior vena cava (IVC) and the tricuspid valve (TV) is critical to close the activation circle. The circuit can be interrupted by radiofrequency ablation of the myocardium between the TV and the IVC, and, in some cases, by ablation between the coronary sinus and TV. Flutter interruption does not mean complete isthmus ablation, as it may remain inducible, requiring further ablation. Despite attaining noninducibility, flutter may recur, and new procedures may be needed for complete ablation. Atrial fibrillation occurs in up to 30% of the cases during follow-up but is generally well controlled with antiarrhythmic drugs that were ineffective in treating flutter before ablation. Some noncommon atrial flutters show circular right atrial activation in a reversed (clockwise) direction, with the same critical areas in the low right atrium, and in these isthmus ablation is effective. Other noncommon flutters have different substrates in the right or left atrium, and mapping has to define specific critical isthmuses as ablation targets in each case. Left atrial flutter circuits remain inaccessible to ablation.