Atypical AFlutter

My ECG results came back today. The note read: Atrial Flutter, appears to be right sided, though somewhat atypical, so we cannot rule out left sided.

What questions should I be asking about these results?

My ep knows immediately wether its right or left (atypical). I had right flutter ablated 2012. Its a near lock 95% cure rate. Outpatient usually. Left or atypical another animal. When i first developed it and it was caught on an ekg about 2017 my ep called it problematic. He ablated it 3/29. Didnt work thus i went to Austin and Dr Natale 8/6. LAA and Cornary Sinus isolated. I could be mistaken but left flutter usually results after a period of time from an afib ablation
T

Thanks T,
I sent you a personal message,

It's actually pretty darn hard to determine right-sided versus left-sided flutter on an EKG. An EKG is a surface electrogram (it's measured on your skin after all) and shows an very attenuated version of the electrical activity on the surface of your heart. To really figure out left vs. right you need to have a mapping catheter in there measuring the electrical activity INSIDE the heart.

Right sided is a very easy ablation. Left sided is an hours long slugfest.

Thanks, Wolfpack. I knew the right side was easier than the left. Have you had an ablation for AFlutter, particularly the left side?

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Pixie
What questions should I be asking about these results?

Not much to ask, really. Like Wolfpack said, right-sided is usually easy to ablate, left-sided can be difficult, and the only way to be sure which it is is to get a catheter in there. My local EP was also unsure if my flutter was right- or left-sided because he just couldn't be certain from EKGs despite having dozens of them to review (I own an EKG machine so he had plenty).

As it turns out, I had both. I had a 250 bpm flutter circuit on the left and a 125 bpm circuit on the right. Ha! Let's see anybody figure that one out from an EKG! The two circuits led to puzzling results like sometimes I had flutter with a variable rate, which I mistook for afib because it was irregular and I didn't even know that was possible.

Anyway, long story short, Natale made short work of both of them once he got in there. I was in 250 bpm flutter when I went into the procedure. He mapped it to the LAA and ablated it. As soon as he did, instead of returning to NSR I dropped to 125 bpm flutter. When he mapped that, he found it on the opposite side in the coronary sinus. And when he ablated that, I returned to NSR where I remain to this day 4 years later.

But don't take my story as anything you should expect. I was an over-ablated mess. I'm just showing how complex these things can be. I would bet money that you have a typical right-sided flutter and it will be a slam dunk to ablate.

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Pixie
Thanks, Wolfpack. I knew the right side was easier than the left. Have you had an ablation for AFlutter, particularly the left side?

No, so far AF-only PVI ablation for me. My dad did develop flutter a decade or so after his AF ablation, so it may be in my future. Hard to say. I've never experienced flutter myself. Knock on wood...

When i was first diagnosed with atypical flutter Dr Holshouser said its left not right. So i assumed he could tell. Now maybe he just knew that right was ablated years earlier and the only flutter left was left sided. Idk. I always was under assumption the ekg could tell but i guess not. Anyway i indeed did have left flutter that Natale also mapped to my LAA and isolated it 13 days ago. So far only one 5 min something a few days ago.

Sometimes it is possible to tell, but not always. Most likely he was pretty sure, but not 100% sure.

I would think the right side is more difficult because one has to make sure not to overheat the AV otherwise they are on a path to getting a pacemaker.

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susan.d
I would think the right side is more difficult because one has to make sure not to overheat the AV otherwise they are on a path to getting a pacemaker.

Avoiding the AV node is easy. A right sided ablation is much easier because it doesn't require a septal puncture, there are no pulmonary veins, and it's not up against the trachea.