"NASCI case of the month: left ventricular apical hypoplasia".

Left ventricular apical hypoplasia is a rare congenital condition. It can cause nonspecific symptoms and can be accompanied by cardiac conduction system alterations such as bundle branch block, atrial flutter (AF) or atrial fibrillation. The diagnosis mostly is made by imaging.

Atrial flutter and embolic risk: The relationship between atrial flutter cycle length and left atrial appendage function.

BACKGROUND: The potential for thromboembolism in atrial flutter (AFL) is different from atrial fibrillation. AFL cycle length (AFL-CL) may be related to reduced left atrial appendage (LAA) function. Very rapid AFL-CL can lead to mechanical and electrophysiological disorders that contribute to lower LAA emptying velocity (LAEV). The aim of this study is to relate atrial flutter cycle length with LAEV and its role in thrombogenesis. METHODS: Cross-sectional study of patients with atrial flutter AFL who underwent transoesophageal echocardiography (TEE) before catheter ablation or electric cardioversion. AFL-CL in milliseconds was measured with a 12-lead EKG or in intracardiac records. RESULTS: We included 123 patients. There was correlation between AFL-CL and LAEV (r = 0.34; p = 0.003) in typical AFL. Cycle length, LA size and atypical flutter were predictors of low LAEV on multivariate analysis. An index multiplying atrial rate (bpm) during the arrhythmia versus left atrial size(mm) >11,728 was associated with spontaneous echogenic contrast and/or left atrial thrombus on TEE (C-statistic = 0.71; CI95%0.60-0.81). CONCLUSIONS: There was a significant relationship between the AFL-CL and LAEV. The LAEV was affected by the LA size, the type of atrial flutter and the AFL-CL. A new index, relating the atrial rate with the left atrial size, was able to identify a higher occurrence of spontaneous echogenic contrast and/or left atrial thrombus.

Imagen de Flúter Atrial en una Paciente con Marcapasos Bicameral: ¿Cuál es el Mecanismo? / Atrial Flutter in a Patient with a Two-chamber Pacemaker. What is the mechanism?

Se presenta el caso de una paciente portadora de un marcapasos bicameral implantado por enfermedad del nodo sinusal. En su primer control postoperatorio presentó un electrocardiograma sugestivo de flúter atrial. Se discuten los mecanismos posibles que resultan de la interacción entre el ritmo propio del paciente y la función del marcapasos y sus manifes taciones electrocardiográficas.

Atrial Flutter in a Patient with a Two-chamber Pacemaker. What is the mechanism? We present the case of a female patient patient in whom a dual-chamber pacemaker was implanted due to sick sinus syndrome. During her first postoperative follow-up visit, her electrocardiogram showed an atrial flutter pattern. The mechanisms of interaction between the patient´s intrinsic rhythm and the pacemaker functions as well as the main electrocardiographic findings are discussed.

Prognostic implications of right atrial ischemic dysfunction in patients with biventricular inferior infarction: transesophageal echocardiographic analysis.

In order to determine the effect of right atrial dysfunction on clinical outcome, six patients with inferior myocardial infarction with extension to right ventricle and right atrium involving only obstructions of the right coronary artery were examined with transesophageal echocardiography (TEE) at the time of the event. Five of the patients were reexamined 15 to 55 months later. Two patients underwent thrombolysis and maintained ratios of right-to-left ventricular diameters of less than 1, as well as normal convexity of the interatrial septum. One patient had spontaneous reperfusion of the right coronary artery, reduction in right ventricular diameter, and normalization of interatrial septum. Another patient underwent delayed angioplasty and manifested a diminished wall movement score (WMS) in the follow-up echocardiogram. One patient died during his first hospitalization with significant right ventricular dilatation, inverted convexity of the interatrial septum, and right atrial thrombosis. The last patient died during follow-up with right ventricular dilatation, increased WMS, right atrial akinesis, and inverted interatrial convexity. Serial TEE examination of patients with infarction of the left ventricular inferior wall is a safe technique for determining the degree of the extension of the ischemic process to the right chambers.

Echocardiographic findings in a contemporary Afro-Caribbean population referred for evaluation of atrial fibrillation or flutter.

Atrial fibrillation and/or flutter is the most common and the most significant cardiac arrhythmia in the Caribbean. This study is an attempt to determine the echocardiographic findings in a current, consecutive series of Afro-Caribbean patients referred for evaluation of atrial fibrillation and flutter. Between May 1998 and June 2000, 50 patients (mean age 67 years, 58% male) had echocardiograms done. Measurements included left atrial dimension (LA), left ventricular end-systolic dimension (LVESD), LV end-diastolic dimension (LVEDD), LV posterior wall thickness (LVPWT) and ventricular septal thickness (VST). Left ventricular ejection fraction (EF) was calculated. LA > 4 cm, LVPWT or VST > 13 mm, and LVEF < 50% were considered abnormal. Atrial fibrillation was seen in 92%, atrial flutter in 8%; 60% were chronic, 40% paroxysmal; 56% had congestive heart failure. The most frequent echocardiographic finding was LV hypertrophy (19/50, 38%). Left ventricular systolic dysfunction was present in 12/50, 24% (25% with LV hypertrophy also). Valvular disease (abnormal appearing valve, no Doppler study), was seen in 9/50, 18%. Normal findings ("lone atrial fibrillation") were seen in 10/50, 20%. Increased LA dimension was seen in 39/50, 78%. Patients with lone atrial fibrillation were younger (mean 56 years) than those with valvular disease (mean 64 years), LV systolic dysfunction (mean 69 years) and those with LV hypertrophy (mean 72 years). Thus, LV hypertrophy, probably secondary to hypertension, is the most frequent echocardiographic finding, with LV dysfunction (such as seen in coronary artery disease) seen less often. Valvular disease and lone atrial fibrillation rates are similar to rates in developed countries.

[Thromboembolic risk factors in atrial flutter. Transesophageal echocardiographic study]. / Factores de riesgo tromboembólico en el flutter auricular. Estudio con ecocardiografía transesofágica.

BACKGROUND: The thromboembolic risk of atrial flutter (AFL) is not well defined. On the other hand, in atrial fibrillation (AF), the echocardiographic demonstration of thrombus or spontaneous echo contrast in the left atria or its appendage, a lower flow velocity in the left atrial appendage, and its reduced mobility, are well known risk factors of thromboembolism. AIM: To study the incidence of these echocardiographic risk factors in patients with AFL. MATERIAL AND METHODS: We prospectively studied 50 consecutive patients with AFL comparing them with two groups of patients with a well known increased risk of thromboembolism: 54 patients with AF and 24 patients with sinus rhythm and severe mitral stenosis (RSEMS). The group of patients with AFL was also compared with a control group of 27 patients with sinus rhythm and no increased risk of thromboembolism. In each group, we studied the presence of thrombi and spontaneous echo contrast in the left atria and left atrial appendage, emptying velocity (Vel A), filling flow (Vel B) and motility of the left atrial appendage and left atrial dimensions. RESULTS: When compared with control patients, AFL subjects had a higher incidence of spontaneous echo contrast in the left atria and left atrial appendage (11 and 42% respectively, p < 0.05); slower flow velocity in the left atrial appendage (Vel A 69.25 +/- 25 and 41 +/- 19 cm/s respectively, Vel B 55 +/- 16 and 46 +/- 20 cm/s respectively, p < 0.05); lower atrial appendage wall motility (4 and 84% respectively, p < 0.001) and a larger left atrium (40 +/- 10 and 45 +/- 0.6 mm respectively, p < 0.05). Patients with AFL had a lower incidence of echocardiographic abnormalities than subjects with AF or RSEMS. Thrombi were found in 2 patients with AFL, 12 patients with AF, 4 patients with RSEMS and in no control patient. CONCLUSIONS: In AFL, there are echocardiographic markers of increased thromboembolic risk in comparison with a control group. Nevertheless, the incidence of these factors is lower than in patients with AF or with RSEMS.

Fetal atrial flutter: diagnosis, clinical features, treatment, and outcome.

OBJECTIVES: To assess clinical features, treatment efficacy, and outcome of fetal atrial flutter. STUDY DESIGN: All atrial flutter cases seen in our unit between 1988 and 1995 were reviewed retrospectively and compared with the pooled data of 37 echocardiographically documented and published cases. RESULTS: Atrial flutter was found in 15 of 49 (30.6%) fetuses who had been referred because of clinically relevant tachyarrhythmia. Mean age at detection was 34+/-4 weeks' gestation. Atrial flutter was incessant in 11 and intermittent in 4, with a mean atrial rate of 442+/-65 beats/min and a mean ventricular rate of 216+/-28 beats/min. A predominance of 2:1 atrioventricular conduction was observed. In 5 of 15 cases another form of arrhythmia (supraventricular tachycardia, chaotic atrial rhythm, ventricular extrasystoles) coexisted with atrial flutter. Eleven fetuses were treated with maternal digoxin, and five subsequently converted to sinus rhythm. Four fetuses received no medication; of these four, two showed brief self-limited episodes of atrial flutter and two were delivered after detection of the arrhythmia. Only one fetus (6.7%), who did not respond to drug therapy, was delivered prematurely because of mild congestive heart failure. Seven neonates were in atrial flutter at birth; rhythm control could be easily achieved with sotalol or digoxin (n = 5), flecainide (n = 1), or electroconversion (n = 1) within the first 2 days of life without any relapse. CONCLUSION: Fetal atrial flutter accounts for approximately one third of all clinically relevant tachyarrhythmia. Although the suppression rate of incessant atrial flutter with digoxin is only 50%, this therapy may be useful for its positive inotropic and negative chronotropic properties. In our experience most fetuses with therapy-resistant atrial flutter and absence of 1:1 atrioventricular conduction do not experience congestive heart failure and do not need to be delivered prematurely. After birth, conversion to sinus rhythm was easily achieved in all neonates.

[Auricular flutter associated with interauricular communication in an infant]. / Flutter auriular asociado a comunicación interauricular en un lactante.

A case of a two year old child with atrial flutter diagnosed at four months of age is presented. The child also had a large atrial septal defect. We were not able to convert the atrial flutter to sinus rhythm with medical treatment of electroshock. However, it did respond to mechanical stimulation during cardiac catheterization. The atrial septal defect was repaired and the patient has not had a recurrence of the flutter.

Echocardiographic findings in a Afro-Caribbean population reffered for evaluation of atrial fibrillation or flutter

Atrial fibrillation and/or flutter is the most common and the most significant cardiac arrhythmia in the Caribbean. This study is an attempt to determine the echocardiographic findings in a current, consecutive series of Afro-Caribbean patients referred for evaluation of atrial fibrillation and flutter. Between May 1998 and June 2000, 50 patients (mean age 67 years, 58 percent male) had echocardiograms done. Measurements include left atrial dimension (LA), left ventricular end-systolic dimension (LVESD), LV end-diastolic dimension (LVEDD), LV posterior wall thickness (LVPWT) and ventricular septal thickness (VST). Left ventricular ejection fraction (EF) was calculated. LA>4 cm, LVPWT or VST>13 mm, and LVEF<50 percent were considered abnormal. Atrial fibrillation was seen in 92 percent, atrial flutter in 8 percent; 60 percent were chronic, 40 percent paroxysmal; 56 percent had congestive heart failure. The most frequent echocardiographic finding was LV hypertrophy (19/50, 38 percent). Left ventricular systolic dysfonction was present in 12/50, 24 percent with LV hypertrophy also). Valvular disease (abnormal appearing valve, no Doppler study), was seen in 9/50, 18 percent. Normal findings ("lone atrial fibrillation") were seen in 10/50, 20 percent. Increased LA dimension was seen in 39/50, 78 percent. Patients with lone atrial fibrillation were younger (mean 56 years) than those with valvular disease (mean 64 years), LV systolic dysfunction (mean 69 years) and those with LV hypertrophy (mean 72 years). Thus, LV hypertrophy, probably secondary to hypertension, is the most frequent echocardiographic finding, with LV dysfunction (such as seen in coronary artery disease) seen less often. Valvular disease and lone atrial fibrillation rates are similar to rates in developed countries. (AU)