Usefulness of excitable gap and pattern of resetting in atrial flutter for determining reentry circuit location

Clinical and experimental data show that type I atrial flutter is due to a reentry mechanism with an excitable gap. To define the location of the reentry circuit of atrial flutter, width of excitable gap, poststimulation cycle and pattern of reset after premature stimulus were analyzed in 18 patients during atrial flutter at multiple atrial sites (high, lateral, posterior and septal right atrium, and coronary sinus). The pattern of reset was defined as flat or increasing whether the return cycle remained unchanged or prolonged with increasing prematurity. Shorter values of the excitable gap were found at the coronary sinus (33 ± 8 ms) and high right atrium (30 ± 10 ms) than at the posterior (43 ± 9 ms) or septal right atrium (45 ± 11 ms). Intermediate values (36 ± 8 ms) were measured at the lateral right atrium. Poststimulation cycle, corrected for atrial flutter cycle length, was shorter in the posterior (6 ± 7 ms) and septal right atrium (5 ± 7 ms) than in the coronary sinus (35 ± 9 ms), and the high (23 ± 10 ms) and lateral right atrium (15 ± 9 ms). A flat pattern of resetting occurred more frequently at the septal (18 of 18 patients) and posterior right atrium (15 of 18) than at the lateral (8 of 18) and high right atrium (2 of 17), and was never observed at the coronary sinus. Atrial flutter was successfully terminated by overdrive atrial pacing in 15 of 18 patients, and termination was more easily obtained from the septal and posterior right atrium. The relation between shortest poststimulation cycle, flat pattern of resetting and widest excitable gap, probably identifies sites closer to the reentry circuit. This pattern is consistently observed at the septal and posterior right atrium. These criteria might be useful to improve efficacy in the electric termination of atrial flutter and in ablative therapy.