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FAQs Coping with A-Fib: A-Flutter

“I have Atrial Flutter that my EP describes as “atypical”. What does that mean? Is it treated differently than typical Flutter? (I’ve had two ablations, many cardioversions, and a Watchman installed to close off my LAA.)”

A-Flutter usually comes from the right atrium.

Atrial Flutter is similar but different from Atrial Fibrillation. Atrial Flutter is characterized by rapid, organized contractions of individual heart muscle fibers (see ECG graphic).

In general, there are two types of Atrial Flutter:

Typical Flutter (from the right atrium)
Atypical Flutter (can come from anywhere)

Typical Flutter

Typical Flutter originates in the right atrium (whereas A-Fib usually comes from the left atrium). Typical Flutter is an organized right atrium rhythm which usually travels around the tricuspid valve annulus, either in a counterclockwise or clockwise manner. This is the most common form of atrial Flutter.

The tricuspid valve forms the boundary between the right ventricle and the right atrium. Deoxygenated blood enters the right side of the heart via the inferior and superior vena cava.

An ablation for Typical Flutter is one of the easier and more effective forms of catheter ablation. The electrophysiologist (EP) makes what is called a Cavo-Tricuspid Isthmus line in the right atrium to block Flutter signals.

If combined with an ablation for A-Fib (highly recommended), the EP makes this lesion set or line either before going through the septum to the left atrium or on the way out.

This blocking line can be made in as little as 20 minutes and usually stops Typical Flutter. It’s highly successful (95%) with low risk.

Atypical Flutter

Atypical Flutter can come from anywhere and is one of the most difficult arrhythmias to map and ablate. Atypical Flutter includes any other Flutter circuit (not traveling around the tricuspid valve), from either the left or right atrium.

These Atypical Flutter circuits are often associated with scar tissue from prior A-Fib catheter or surgical procedures, but can arise from spontaneous left and/or right atrial scar. One form can travel around the mitral valve annulus, but many other Atypical Flutter circuits are possible. These can be difficult to map and ablate, and there can be multiple Atypical Flutter circuits in a single patient.

Atypical Flutter often appears, as probably in your case, after a successful ablation for A-Fib. It’s often the last arrhythmia circuit that needs to be ablated to restore a patient to sinus.

Treatment for Your Atypical Flutter

Antiarrhythmic Drugs? Today’s antiarrhythmic drugs leave a lot to be desired. They are effective for only about 40% of patients, tend to lose their effectiveness over time and have bad side effects. While they aren’t considered a “cure” for A-Fib, they can be helpful to improve A-Fib symptoms on a temporary basis.

For more about ablation for Atypical Flutter, see my 2020 AF Symposium report, Live Case of Difficult A-Fib Ablation of Atypical Flutter performed by Dr. Kevin Heist, Mass. General Hospital.

For Atrial Flutter, in particular, antiarrhythmic drugs are even less effective. In fact, they sometimes make Flutter worse by slowing conduction which favors the organization of Flutter circuits.

Master EP for Complex Ablation: Treating your Atypical Flutter is often a complex ablation procedure and isn’t for the faint of heart. You need to find a top “master” EP, a highly skilled EP with a high success rate with difficult A-Fib cases, and Atypical Flutter, in particular.

This complex ablation requires an EP with both the experience and the tenacity to find and ablate these often-elusive Atypical Flutter signals. (Email me, I can suggest several “master” EPs.)

Don’t just go to the EP whose office is near you. Go to the best, most experienced EP you can reasonably find. Be prepared to travel.

I know it’s a lot of effort. But you have to work at finding the right EP for you and your Atrial Flutter.

Learn more about Flutter: Most of the information on applies to Atrial Flutter too. But I have also written specifically about Atrial Flutter.

So, I offer you a list of my top articles about Atrial Flutter. See My Top 5 Articles About Atrial Flutter.

Reference for this article
Thanks to Embry Rucker for this excellent question.

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