Atrial flutter

Can you distinguish right-sided (typical) atrial flutter from left-sided (atypical) atrial flutter via EKG? If so, how?

I’m not asking for me - thankfully I’m in NSR. My dad (former AFer) was complaining of problems over the weekend, so I took a 30 second rhythm strip with my Kardia. Rate was 149bpm but had fairly evenly spaced QRS complexes. I called it flutter and told him to double his metoprolol. He got into his (and mine, too) cardiologist today, who said a-fib, but when my dad asked about flutter he took another look at the 12-lead and changed his mind. He called it flutter and told Dad to double his metoprolol. (Yes, I’m grinning a little bit. This site is a treasure trove of information!)

As of today his rate is 64, so I think he converted on his own. Follow-up tomorrow or Wednesday so we’ll see. I told him to ask the right vs left question at the next appointment, but I’d like to know more about the differential diagnosis if anyone can help.

You'll never be able to distinguish between left and right flutter with a Kardia. Good call on recognizing the basic hallmarks of flutter vs. afib. Come forward and collect your honorary EP badge. :-)

You need a full 12-lead ECG to distinguish between right and left flutter, and then you'll need a fellowship in electrophysiology and 30 years of experience to go with it. Flutter was my primary demon for almost seven years, and three highly qualified EPs looked at dozens of 12-lead ECGs from me and the best any of them could ever say was "probably" typical counter-clockwise right-sided flutter or "probably" the opposite. It's just too subtle to reliable distinguish even with a 12-lead ECG and downright impossible with a Kardia because you need the other leads.

Good luck with the metoprolol because flutter is often resistant to rate control. If it doesn't slow it down, don't let them keep upping the dose. That's what someone did to me once and the result was they crashed my BP and changed me from a very uncomfortable but functioning person with a very high heart rate into a gray, sweating, puking pile of decompensation with a BP of 50/nothing.

Yeah, I didn’t think I’d get any farther with the Kardia. His cardiologist has the 12-lead. I was wondering if you can tell right vs left-sided by the 12-lead. I’m guessing it’s tough, considering the cardio missed it on the first try. The 12-lead trace is too short, in my opinion. The Kardia, although noisy as crap, at least grabs 30 seconds’ worth of data - enough to see regularity in the QRS complexes which made me think flutter and not fib.

Yeah, it's tough to distinguish. I wouldn't fault anyone for not being sure.

If it ultimately comes to another ablation, the right-sided variety should be pretty easy. Is left-sided flutter as complicated as AF ablation? Should we be seeking a more elite EP for that type of work? Additionally he has anti-phospholipid syndrome. His EP who performed his AF ablation 10 years ago at UNC (boo - Tarheels - boo) won't do another due to the anti-phospholipid syndrome. That's probably a good thing because they did cause a stroke during the index AF ablation and he had nounal effasia for a few weeks afterwards. I give that EP department low marks for that fiasco. Would the anti-phospholipid syndrome be an issue for a more elite EP team? He has been on warfarin since forever because of it. I'm guessing any future ablation, if it is an option, is going to want to switch that to Eliquis beforehand.

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wolfpack
Is left-sided flutter as complicated as AF ablation? Should we be seeking a more elite EP for that type of work?

Yes, it certainly can be. Three EPs failed to address my left-sided flutter successfully in four attempts, two of whom I would consider at least almost elite. (Top dogs at Ivy League institutions.)

I don't know a darn thing about anti-phospholipid syndrome so can't offer any help there.



Edited 1 time(s). Last edit at 02/28/2018 12:10AM by Carey.

Anti-phospholipid Syndrome is a rare autoimmune disorder that occurs mostly in pregnant women. Dad’s a 71-year old male. Go figure...

It’s kind of like “lupus light”, and it causes clotting. He lost the lower lobe of his left lung to it because the pulmonary veins became obstructed. That was 4 years ago. Hence the continued warfarin. Why Eliquis won’t work for anti-phospholipid I don’t know. Probably hasn’t been studied.

I’ve had several anti-nuclear antibody (ANA) tests and they all come back negative. So as far as I know my immune system doesn’t attack fat metabolites. Thankfully!