1. CLINICAL CONFERENCE By Faizul Haque Date Presented: 12/4/2007 Department of Cardiology University of Illinois at Chicago By Faizul Haque Date Presented: 12/4/2007 Department of Cardiology University of Illinois at Chicago

2. 58 y/o F who had initially presented to outside hospital for severe palpitations + lightheadedness: –she states the sx of palpitations started within 2d prior to recent admission: she has had intermittent hx of palpitations since 2003 –she has had some associated LH: denies any syncopal episodes –patient denies any CP/SOB/DOE per review –Patient referred to UIC EP for further evaluation/management 58 y/o F who had initially presented to outside hospital for severe palpitations + lightheadedness: –she states the sx of palpitations started within 2d prior to recent admission: she has had intermittent hx of palpitations since 2003 –she has had some associated LH: denies any syncopal episodes –patient denies any CP/SOB/DOE per review –Patient referred to UIC EP for further evaluation/management CASE

3. pMHx/pSurghx: –Hx of mitral stenosis + severe MR MVR+TV repair in 4/2004 at outside hospital Redo bioprosthetic MVR + TV repair recently in 8/07 at outside hospital –Hx of HTN –Hx of depression –Hx of HL pMHx/pSurghx: –Hx of mitral stenosis + severe MR MVR+TV repair in 4/2004 at outside hospital Redo bioprosthetic MVR + TV repair recently in 8/07 at outside hospital –Hx of HTN –Hx of depression –Hx of HL Past Hx

4. O: V/S – 97.1 – 104/60 - ~100bpm Gen: NAD; resting upright Neck: JVP at 6cmH20 Chest: b/l CTA; no wheezes or crackles noted CV: rr nl s1s2 no s3s4 noted; no RV impulse Abd: +BS Ext: no b/l LEE noted O: V/S – 97.1 – 104/60 - ~100bpm Gen: NAD; resting upright Neck: JVP at 6cmH20 Chest: b/l CTA; no wheezes or crackles noted CV: rr nl s1s2 no s3s4 noted; no RV impulse Abd: +BS Ext: no b/l LEE noted Physical Exam:

5. Medications: current –Metoprolol 12.5mg BID –ASA 325mg qD –Lasix 20mg qD –Zocor 20mg qHS coumadin 5mg + 2.5mg alternating qD Medications: current –Metoprolol 12.5mg BID –ASA 325mg qD –Lasix 20mg qD –Zocor 20mg qHS coumadin 5mg + 2.5mg alternating qD Med Hx:

8. TTE: 11/07 –1. Left atrium mildly dilated: 4.41cm –2. Global normal LV function: EF 50-55% –3. Global normal RV size + function –4. Peak TV TR at 2.7m/sec, PA 38mmHg TTE: 11/07 –1. Left atrium mildly dilated: 4.41cm –2. Global normal LV function: EF 50-55% –3. Global normal RV size + function –4. Peak TV TR at 2.7m/sec, PA 38mmHg Clinical Questions:

9. Prototypic macroreentrant atrial rhythm Typical/atypical atrial flutter: Reentrant rhythm in the R atrium constrained anteriorly by the tricuspid annulus and posteriorly by the crista terminalis and eustachian ridge Typical atrial flutter usually defined by counterclockwise versus clockwise rotation along the macroreentrant circuit Prototypic macroreentrant atrial rhythm Typical/atypical atrial flutter: Reentrant rhythm in the R atrium constrained anteriorly by the tricuspid annulus and posteriorly by the crista terminalis and eustachian ridge Typical atrial flutter usually defined by counterclockwise versus clockwise rotation along the macroreentrant circuit Atrial Flutter: Basics

10. Hx

11. Typical atrial flutter [Type I] Identically recurring sawtooth flutter [F] waves best visualized in II, III, AVf + V1 Inverted [negative] flutter waves in II, III, AVf due to counterclockwise reentry Upright [positive] flutter waves in II, III, AVf present during clockwise reentry Involves the cavotricuspid isthmus [CTI] Atypical atrial flutter Not involving CTI: could be from prior atrial surgery/ablation, idiopathic fibrosis, L atrial origination around the mitral annulus Typical atrial flutter [Type I] Identically recurring sawtooth flutter [F] waves best visualized in II, III, AVf + V1 Inverted [negative] flutter waves in II, III, AVf due to counterclockwise reentry Upright [positive] flutter waves in II, III, AVf present during clockwise reentry Involves the cavotricuspid isthmus [CTI] Atypical atrial flutter Not involving CTI: could be from prior atrial surgery/ablation, idiopathic fibrosis, L atrial origination around the mitral annulus Aflutter: ECG Criteria

12. Which patients are considered ideal candidates for catheter-based atrial flutter ablation? Ideally patients with cavotricuspid isthmus dependent atrial flutter or typical atrial flutter as opposed to atypical CTI-independent scenarios Which patients are considered ideal candidates for catheter-based atrial flutter ablation? Ideally patients with cavotricuspid isthmus dependent atrial flutter or typical atrial flutter as opposed to atypical CTI-independent scenarios Clinical Questions:

13. Aflutter Ablation

14. Clinical Questions: