Relationship between polarity of the flutter wave in the surface ECG and endocardial atrial activation sequence in patients with typical counterclockwise and clockwise atrial flutter

The relation between ECG and activation patterns within atria in typical atrial flutter (AFL) patients (pts) has not been defined due to the lack of simultaneous multisite right and left atrial mapping. In 13 pts with AFL, a Halo catheter was positioned along tricuspid annulus and multipolar catheters were placed in right atrial appendage, His bundle region, coronary sinus (CS), proximal portion of right pulmonary artery (Bachmann's bundle region, BB) and esophagus (Eso) to record right and left atrial activation simultaneously. In counterclockwise (CCW) AFL (11 pts), 9 showed negative flutter wave (F) and 2 positive F in the inferior leads. CCW/negative F; CS electrograms (EGs) were proximal to distal, Eso EGs were inferior to superior and BB activation was later than CS and Eso. positive F; BB activation was earlier than CS. Eso EGs were superior to inferior or simultaneous. In clockwise (CW) AFL (7 pts), 5 showed positive F and 2 negative F. CW/positive F; BB activation preceded Eso and CS. Eso EGs were superior to inferior. CS EGs were proximal to distal (1), middle to proximal, distal (3) or proximal, distal to middle (1). negative F; CS EGs were proximal to distal. CS activation was earlier than BB or CS and BB activation were simultaneous. Eso EGs were inferior to superior. Impulse conduction to the left atrial free wall through either lower or upper interatrial connection is a major determinant of ECG morphology in AFL.