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Atrial Flutter: From Mechanism to Treatment FREE TO VIEW

John H. Jentzer, MD
Chest. 2001;120(2):692. doi:10.1378/chest.120.2.692
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Albert L. Waldo, MD. Armonk, New York: Futura Publishing Company Inc, 2001; 64 pp; $16.00

The publication of Atrial Flutter: From Mechanism to Treatment is proof that good things can come in small packages. This 64-page monograph covers the topic of atrial flutter starting with a classification of atrial flutter types, proceeding to experimental models and human validation, and concluding with management of the patient with atrial flutter. The text is concise and well written, the illustrations are on-point, and an extensive bibliography will guide the interested reader to articles of further interest, both historical and clinical.

The different classifications of atrial flutter have led to confusion for both clinicians and students of this dysrhythmia. Is this type I or type II flutter? Typical or atypical flutter? Clockwise or counterclockwise? Dr. Waldo takes the reader fluidly through this inconsistent area using representative electrocardiograms and illustrations, concluding with a review of the soon-to-be-published classification of atrial flutter, by the European Society of Cardiology/North America Society of Pacing and Electrophysiology Working Group.

The discussion on mechanisms is divided between animal models and studies in human patients, with the section on animal models being particularly strong. Taking a historical approach, the contributions of Lewis et al, Frame et al, Allessie et al, and Dr. Waldo himself are described clearly, bringing the reader logically to our current level of understanding of the pathophysiology of atrial flutter. I particularly enjoyed Figure 6, a reproduction of the illustration and text from Dr. Lewis’ 1920 article published in Heart, which outlines a very accurate model of atrial flutter despite the limited technology available at that time. The companion section, concerning studies in humans, bridges the gap between basic science and clinical medicine. The entrainment techniques that confirmed a reentrant mechanism with an excitable gap are described, as are the right atrial mapping studies that delineated the anatomy of the atrial flutter circuit. These studies laid the foundation for the definitive cures now possible with radiofrequency ablation. Missing are intracardiac electrograms from clinical electrophysiology studies that would have further made the point that atrial flutter is due to macroreentry within the right atrium. Furthermore, examples of concealed entrainment from the atrial flutter isthmus would have more clearly proven the rationale for targeting this area during ablative therapy.

The section on medical management of atrial flutter is concise, including a discussion of pharmacologic treatment of both acute and chronic flutter that is clinically relevant and quite up-to-date. The description of flutter occurring after the suppression of atrial fibrillation treated with intracardiac antiarrhythmic agents is one such example. This section is a distillation of current information combined with clinical judgment, adding to the wealth of clinical “pearls” sprinkled throughout Dr. Waldo’s monograph.

Catheter ablative therapy for atrial flutter is the one notable weakness in this book. The review and a single illustration cover this area in adequate detail for the generalist. However, with> 90% of all atrial flutter being curable by radiofrequency ablation, I would have expected intracardiac electrograms of clockwise flutter, counterclockwise flutter, and complete isthmus block, plus examples demonstrating the use of the newer, computer-assisted mapping systems. A discussion of strategies to evaluate incomplete isthmus block during ablative therapy also would have been appropriate, and together, these additions would have made the section on catheter ablative therapy more complete.

This volume will be a welcome addition to the library of anyone interested in arrhythmias. For a student, generalist, or cardiologist this monograph provides useful information written by an eminent and experienced investigator in the field. For the electrophysiologist, Atrial Flutter: From Mechanism to Treatment will be one of several useful works on the bookshelf.

Northeast Cardiology Associates Bangor, ME




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