Surface Electrocardiographic Characteristics of Right and

Left Atrial Flutter

Andres Bochoeyer, MD*; Yanfei Yang, MD*; Jie Cheng, MD, PhD; Randall J. Lee, MD, PhD;
Edmund C. Keung, MD; Nassir F. Marrouche, MD; Andrea Natale, MD; Melvin M. Scheinman, MD

BackgroundThere is little information about the surface expression of non cavotricuspid isthmus (CTI) dependent
right atrial (RA) or left atrial (LA) flutter circuits.
Methods and ResultsWe retrospectively evaluated 32 episodes (in 26 patients) of atypical RA and 22 episodes (in 21
patients) of LA flutter. The surface ECG of 13 patients with lower-loop reentry was similar to that of their pattern during
counterclockwise (CCW) CTI atrial flutter (AFL), except for decreased amplitude of the terminal forces in the inferior
leads. In 11 of 24 episodes characterized by high or multiple breaks over the crista, the ECG showed changes that
depended on the initial activation sequence of the LA. In 7 of 8 episodes of upper-loop reentry, the ECG pattern
completely mimicked that for clockwise (CW) CTI AFL. All 11 patients with an LA septal circuit showed a typical ECG
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pattern characterized by prominent forces in lead V1 with flat deflections in the other surface leads. Eleven patients with
other LA circuits had a more variable pattern but showed decreased voltage in the inferior leads compared with that of
a group with CCW-CTI AFL (1.61 vs 2.680.7 mV, respectively; P0.05).
ConclusionsThe RA surface-ECG patterns different from those of CCW or CW-CTI could still be CTI dependent. In
contrast, a typical CW-CTI surface pattern was always seen in patients with upper-loop reentry, which was nonCTI
dependent. LA AFL circuits had either flat or low-amplitude forces in the inferior leads. (Circulation. 2003;108:60-66.)
Key Words: electrophysiology atrial flutter mapping catheter ablation

A lthough a large variety of atrial flutter (AFL) circuits

have been defined,1 8 there are few data that correlate
known AFL circuits with surface ECG patterns. The purpose
flutters were generally sustained (30 seconds) and allowed for
mapping and ablation.

Left Atrial AFL

of this study was to define the ECG patterns of flutter circuits
in an effort to help localize the flutter pathway.
Methods
Study Population
Right Atrial AFL
This study retrospectively analyzed consecutive patients referred for
catheter ablation of AFL. The patients (n372) were recruited from
the University of California at San Francisco from January 1996 to
August 2000.
Patients with clockwise (CW) or counterclockwise (CCW)
cavotricuspid isthmus (CTI) dependent flutter (CTI-AFL; n328
patients) and 18 patients with prior cardiac surgery were excluded
from study. We studied 26 patients who had experienced 32 episodes
of atypical right atrial (RA)-AFL. In 20 of 26 cases, the patients also
had CCW or CW CTI-AFL. Among these 32 episodes of atypical
flutter, 20 (63%) were spontaneous and 12 were pacing induced. The
We included only those patients with left atrial (LA)-AFL circuits
without atriotomy in whom a complete electroanatomic map
(CARTO) was available. Eight were excluded because of an incom-
plete map. A total of 21 consecutive patients with 22 episodes of LA
macroreentrant circuit were analyzed; 17 of 21 were studied at the
Cleveland Clinic. All patients with LA-AFL were studied during
their sustained, clinically manifest arrhythmias.
Analysis of the ECG
We compared simultaneous surface and intracardiac recordings
and/or CARTO maps with the surface recordings. We also compared
surface recordings from our study patients with 38 consecutive
patients with CCW CTI-AFL who underwent successful CTI abla-
tion. Surface flutter waves were usually analyzed during higher
(2:1) grades of atrioventricular block to avoid superimposition of
the flutter on T waves. In 3 instances, recordings of 2:1 block were
used because the P or flutter waves that preceded the QRS complexes
were free of T waves.

Received December 31, 2002; revision received April 1, 2003; accepted April 9, 2003.
From the Cardiovascular Research Institute and Section of Cardiac Electrophysiology (A.B., Y.Y., R.J.L., M.M.S.), University of California, San
Francisco; Texas Heart Institute, St Lukes Episcopal Hospital, Houston, Tex (J.C.); the Veterans Affairs Medical Center (E.C.K.), San Francisco, Calif;
and the Section of Cardiac Electrophysiology (N.F.M., A.N.), Cleveland Clinic Foundation, Cleveland, Ohio.
*Drs Bochoeyer and Yang are cofirst authors.
Guest editor for this article was Hein J.J. Wellens, MD, Cardiovascular Research Institute, the Netherlands.
Presented in abstract form at the 22nd Annual Scientific Sessions of the North American Society of Pacing and Electrophysiology Boston, Mass, May
25, 2001.
Correspondence to Melvin M. Scheinman, MD, Cardiac Electrophysiology, University of California, San Francisco, 500 Parnassus Ave, MU E 4S, Box
1354, San Francisco, CA 94143-1354. E-mail scheinman@medicine.ucsf.edu
2003 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org DOI: 10.1161/01.CIR.0000079140.35025.1E

60

TABLE 1. Clinical and Electrophysiological Characteristics of
Patients With Atypical Flutter
RA LA
(n26) (n21)
Age, y, meanSD 5913 678.6 0.03
Male sex, % (n) 92 (24) 71.5 (15)
History of atrial fibrillation, % (n) 61 (16) 71.5 (15)
Structural heart disease, % (n) 19 (5) 62 (13)
CL, ms 25240 297.564
LA size, mm 414 464
Electrophysiology Study
The study was approved by the University of California at San
Francisco and Cleveland Clinic institutional review boards. Antiar-
rhythmic drugs were discontinued for at least 5 half-lives before the
study, except for 11 patients who were treated with amiodarone.
The study was performed as previously described by using
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recordings from a 20-pole halo, His bundle, and coronary sinus (CS)
catheters.7 The distal pole of the halo catheter was positioned at 7
oclock on the tricuspid annulus (TA) in the left anterior oblique
projection. Twelve-lead ECGs and intracardiac recordings were
obtained and displayed simultaneously. Entrainment mapping was
attempted in all patients at a cycle length (CL) of 10 to 30 ms less
than the flutter CL. Concealed entrainment was present when the
difference between the tachycardia CL and postpacing interval was
25 ms with identical intracardiac activation sequence and surface
flutter wave morphology (when possible). Electroanatomic mapping
with the CARTO system (Biosense, Cordis-Webster Inc) was avail-
able for 2 patients with atypical RA-AFL and for 21 patients with
LA-AFL. Low voltage was defined as a voltage amplitude 0.1 mV
and scar that showed no recordable activity. Entrainment mapping
was attempted from various sites in those with lower-loop reentry
(LLR) and upper-loop reentry (ULR). In all patients with LLR,
concealed entrainment was present in the CTI but was absent from
the CTI in those with ULR. CTI ablation was successful in
arrhythmia termination and resulted in a lack of arrhythmia induc-
ibility for all patients with LLR.
Statistics
All numeric variables are expressed as meanSD. A value of
P0.05 was considered statistically significant. Mean voltage com-
parisons were made with use of a t test for a 2-tailed distribution with
2 samples of unequal variance. Sensitivity and specificity were
calculated by using Fishers exact probability test.
Results
RA Flutter
This group consisted of 24 men and 2 women with an average
age of 5913 years. The demographic data for patients with
RA-AFL is detailed in Table 1. In both patients who changed
from CCW to LLR or from CW to ULR, the CL decreased
from 266 to 253 ms (P0.02) and from 259 to 250 ms
(P0.03), respectively.
Counterclockwise LLR
A total of 19 patients with 24 episodes showed a pattern of
LLR, which involves a breakthrough over the crista with the
circuit around the inferior vena cava; hence, LLR is a
CTI-AFL. We found 3 different ECG patterns for patients
with LLR. The first pattern was previously described by
Cheng et al9 and involved a wavefront break over the low
Bochoeyer et al ECG Characteristics of Atypical Flutter 61
P
0.11
0.48
0.002
0.005
0.001
Figure 1. Sustained, spontaneous AFLs with 2 different CLs
from same patient. Tracings on left show 12-lead ECG in a
patient with CCW-AFL with CL of 285 ms. Adjacent 12-lead
ECG was recorded during LLR. Arrows (left-hand panel) point to
decrease in inferior forces with LLR and slight changes in V1
(arrow). Tracings on right show intracardiac recordings during
both CCW and LLR. Schema below shows LLR with early break
(marked by asterisk) in the region of low lateral RA (TA1). Con-
version of CCW to LLR is associated with increase in transisth-
mus conduction time (TA1-CSPX). Shortening of tachycardia CL
with LLR is responsible for increase in isthmus conduction time.
Arrows (right-hand panel) point to activation wavefront, and
refers to areas of collision. SVC indicates superior vena cava;
IVC, inferior vena cava; CSds, distal CS; CSpx, proximal CS; and
CT, crista terminalis.
lateral RA (Figure 1). This circuit was found in 13 of 24
episodes and was usually associated with a slight decrease in
the amplitude of the late positive deflection in the inferior
leads. It was thought that the decrease in the late inferior
forces was caused by an impulse collision over the lateral
portion of the RA, which served to cancel the forces caused
by late craniocaudal lateral RA activation. Because activation
of the septum and LA remains the same as with CCW
CTI-AFL, the AFL wave patterns remain very similar.
The second ECG pattern involved a total of 11 of 24
episodes that showed wavefront breaks over more superior
portions of the TA. An illustrative example of a high break
is shown in Figure 2A and is characterized by advancement of
the atrial electrogram from the His bundle region compared
with the CS recordings during CCW-AFL. Of note was the
finding that the surface recordings were identical during
CCW CTI-AFL when compared with the LLR pattern. We
interpreted this finding as being due to capture of the LA from
the CS connection. The wavefront collision occurred high
over the septum, and hence, most of lateral wall was still
activated in a craniocaudal direction.
Figure 2B shows another example of LLR with a high
break over the TA6. In this patient, the change to a higher
break site (TA8) was associated with a marked change in the
surface ECG morphology. Note that the surface ECG during
LLR1 (with the break at TA6) showed a pattern that mimicked
CCW-AFL. With conversion to the higher break (TA8), the
surface ECG pattern was now more consistent with that seen
in CW-AFL. We explain this finding by assuming earlier
 62 Circulation July 8, 2003
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Figure 2. A, Left-hand panels show 12-lead ECGs of spontaneous
episodes of CCW and LLR. Right-hand panels show intracardiac
recordings during CCW and LLR. Note that during LLR, patient
developed high cristal break over TA9 (see schema). High break
explains early activation over RA roof as well as advancement of
atrial deflection on His bundle electrogram relative to CS record-
ings. TA8TA10 electrograms are probably out of plane relative to
His atrial recordings, because they show small changes relative to
that from His. Direction of both LLR and CCW wavefronts are
identical (caudocranial) and explain why 12-lead ECGs (left-hand
panels) are identical for both circuits. Isth indicates cavotricuspid
isthmus. B, Serial recordings from patient with CCW-AFL (not
shown) who developed 2 patterns of LLR. Left-hand panel shows
surface ECGs of both, and right-hand panel shows corresponding
intracardiac recordings. In 1 pattern (LLR-1), 12-lead ECG (extreme
left) shows flat flutter waves in inferior leads and positive flutter
waves in V1 (see arrows). In endocardial recordings shown on right,
LLR-1 is characterized by cristal break over TA6 (marked by aster-
isk), whereas LLR-2 shows higher break (TA8), as shown in schema
at bottom. Note that higher cristal break in LLR-2 again results in
earlier activation of His bundle atrial electrogram relative to CS
(compare LLR-2 with LLR-1). Larger circuit (LLR-2) is associated
with shorter transisthmus conduction time, whereas shorter circuit
(LLR-1) shows opposite trend, suggesting that circuit size deter-
mines isthmus conduction time. Surface ECG leads for LLR-2 (left)
shows positive flutter waves in inferior leads and negative flutter
waves in V1 and are explained by craniocaudal activation of sep-
tum and LA. CSos indicates the ostium of CS.
activation of the septum and anterior LA over Bachmanns
bundle, with the wavefront akin to that observed in CW-AFL.
The third type of flutter circuit was observed in 9 patients
and was characterized by LLR, with multiple, early breaks
over the lateral TA. A very unusual ECG pattern evolved as
Figure 3. Left-hand panel shows 12-lead ECGs in patient with
CCW-AFL and LLR with multiple cristal breaks. Right-hand pan-
els show corresponding intracardiac recordings. CCW pattern is
characterized by caudocranial activation of LA and is associated
with typical surface morphology. During LLR (right), early breaks
(asterisks) over TA1, TA6/7, and TA10 are manifested. Note that
during LLR (right), atrial electrogram from His bundle region is
advanced relative to that from CSos, compared with sequence
during CCW-AFL. In addition, changes in atrial activation
sequence and morphology are observed in atrial electrogram
from His bundle recording site between CCW and LLR patterns
(see change in arrow orientation over His recording site). We
explain both early TA10 activation relative to TA8/9 as well as
changes in His atrial electrogram to more superior cristal break
(see schema). Schema shows early breaks over crista in regions
corresponding to TA1, TA6/7, and TA10. We suggest that surface
patterns observed for LLR and multiple breaks (characterized by
diminished inferior flutter wave and negative flutter wave in V1)
results from competition in activation of LA from both CS as
well as from right-to-left connections from Bachmanns bundle
Isth indicates cavotricuspid isthmus.
the flutter circuit changed from CCW to LLR with multiple
breaks (Figure 3). The flutter wave in V1 changed from
positive to negative and was associated with diminished late
forces in the inferior leads. The latter is explained by a
collision of wavefronts over the lateral wall, with cancellation
of the late craniocaudal forces. The change in polarity of V1
might result from slightly earlier activation of the LA from
Bachmanns bundle (Figure 3).
Clockwise ULR
Another flutter pattern was characterized by a circuit con-
fined to the upper portion of the RA that was nonCTI
dependent. There were 8 episodes of CW-ULR in 7 patients:
5 were spontaneous and 3 were induced by pacing. Seven of
the 8 episodes showed breakthrough over the low crista
terminalis, with wavefront collision over the midlateral TA.
An example is shown in Figure 4. Note that there is no change
in the surface ECG pattern despite clear-cut evidence of
change from a typical CW circuit to 1 with a wavefront
collision in the CTI, which was associated with an early break
over the low lateral TA. This pattern is explained by the
identical craniocaudal activation sequence of the septum and
LA for both flutter circuits. One patient had a persistent 2:1
atrioventricular conduction, which impaired our ability to
compare the surface pattern with CW CTI-AFL.
 Bochoeyer et al
Figure 4. Right-hand panel records episode of CW flutter, which
spontaneously evolved into a pattern of ULR) with early break-
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through at TA3. Two surface ECGs (left-hand panel) are, how-
ever, identical, because 2 wavefronts during ULR (see endocar-
dial recordings at right) collide at isthmus (Isth) and do not
result in any change in activation sequence of LA, septum, or
caudocranial activation of lateral RA.
LA Flutter
The demographic pattern for these patients is detailed in
Table 1. The LA-AFL patients were separated into 3 groups.
LA Septal Circuit
We observed 11 episodes of LA-AFL around the left fossa
ovalis. All patients showed an ECG pattern characterized by
a dominant positive or multiphasic flutter wave in V1 with flat
or isoelectric flutter waves in the others leads (Figure 5A).
CARTO mapping in these patients showed either CCW or
CW revolution around the left side of the septum primum
(Figure 5B). Concealed entrainment was found in the isthmus
between the right pulmonary veins and the left septum
primum. We failed to terminate the flutter circuit by radio-
frequency ablation in 1 patient.
ECG Characteristics of Atypical Flutter 63
Mitral Annulus AFL
Three patients had a reentrant CCW circuit around the mitral
annulus. All had concealed entrainment from both the CS and
mitral annulus. Two had a surface ECG pattern that showed
prominent, positive P waves in V1/V2, with inferior leads that
showed 1-mV positive or multiphasic waves (Figure 6). The
third case had an ECG pattern that mimicked a typical CCW
pattern, except for a negative P wave of 1 mV in lead I. In
these patients, the mitral annulus was the anterior boundary,
and low-voltage areas in the posterior wall served as the
posterior boundary; successful ablation was achieved in 2 of
the 3 patients.
Posterior Wall Scar Circuits
There were 8 patients who had low-voltage or scarred areas
over the LA posterior wall and posterior scar circuit. The
surface ECG of 4 of them mimicked typical CCW CTI-AFL
patterns in terms of P-wave orientation, except for 1 patient,
whose ECG showed a negative deflection in V1 without the
classic sawtooth pattern in the inferior leads. One patient
had a surface ECG with a low-voltage CW pattern, and
another 2 cases showed the characteristic LA septal circuit
pattern previously described (Figure 7). One patient had a
fixed 2:1 atrioventricular block, which precluded definition of
the surface wave morphology. Ablation was successful in
terminating these circuits in all 8 patients.
Surface ECG Comparison
Comparison of the 12-lead ECG between those with LA-AFL
and those with CCW CTI-AFL is detailed in Table 2. Inferior
leads in all patients with the LA septal circuit pattern had
almost flat-line recordings. The maximal amplitude in any of
the 3 inferior leads (II, III, aVF) was significantly smaller for
those with mitral annulus or posterior wall scar circuits
compared with those with CCW CTI-AFL (1.61 vs
2.680.7 mV, P0.05).
Figure 5. Representative example from
patient with LA septal circuit. A, ECG
with a pattern characterized by domi-
nant, positive P wave in V1 with near-
isoelectric P waves in other leads. B,
CARTO map illustrates LA septal circuit
in left anterior oblique projection. The
circuit involves LA septum, with func-
tional barriers between septum primum
(SP), right superior and inferior pulmo-
nary veins (RSPV-RIPV), and mitral annu-
lus (MA).
 64 Circulation July 8, 2003
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Discussion
Major Findings
We found that surface flutter recording for those with
LA-AFL might often be an inadequate indication of CTI-
AFL, whereas LA-AFL shows even more inhomogeneous
patterns. Previous elegant animal studies showed that flutter
wave polarity was dependent on the activation sequence of
the LA,10 13 and this principle has been confirmed in human
studies.14 16 More recently, studies with 62-lead body-surface
mapping in humans with CCW-AFL showed evidence that
the terminal positive deflections in the inferior leads could be
caused by late craniocaudal activation of the lateral RA
wall.17 We used these principles to explain the relation
between surface and endocardial recordings.
Figure 6. Surface and endocardial re-
cordings from patient with CCW mitral
annulus circuit, with CL of 310 ms. Sur-
face ECG (A) shows low-amplitude flutter
waves in inferior leads and prominent,
positive waves in V1/V2. B shows CARTO
maps in both anteroposterior (AP) and
caudal left anterior oblique (LAO) proj-
ection. Low-voltage areas and scar are
identified near ostuim of left superior pul-
monary vein (LSPV). Dark red points
denote sites of concealed entrainment.
Ablation line connecting LSPV with mitral
annulus resulted in tachycardia
termination.
Lower-Loop Reentry
The surface ECG pattern was very similar for those with LLR and
CCW CTI-AFL. For some, the changes were manifested by a
decreased amplitude of the late positive waves in the inferior leads,
probably as a result of wavefront collision over the lateral RA wall.
Of interest was the finding that high cristal breaks could be
associated with a CW pattern (Figure 2B). Even more interesting
surface patterns were recorded with LLR circuits and multiple
cristal breaks (Figure 3). These surface patterns were typical for
neither CCW nor CW-AFL and emphasize the need for careful
entrainment mapping of the CTI to document its involvement.
Upper-Loop Reentry
ULR is a circuit with CW orientation in the upper RA with
wavefront collision in the CTI. In our series of 7 patients with
Figure 7. Surface ECG in A and
3-dimensional map of patient with poste-
rior wall macroreentry (B). Cranial right
anterior oblique (RAO) view shows that
circuit goes around scar (gray area)
located at roof of LA, with CL of 330 ms.
Another scar is also seen in anterior
mitral annulus (MA), and arrhythmia was
terminated with radiofrequency applica-
tion, sealing channel between these 2
scars. There is third scar close to left
superior pulmonary vein (LSPV), which
provides potential for another circuit.
 Bochoeyer et al
TABLE 2. Surface ECG Features: Comparison of Mean Voltage (in mV)
RA
CCW
(n38)
Inferior leads* 2.620.7
Lead I 0.0050.4
V1 1.970.35
*MeanSD of maximal amplitude in lead II, III, or aVF.
P0.05 by t test compared with CCW.
Only 1 patient had negative flutter wave in lead I.
PNS compared with CCW.
8 ULR circuits, we could not detect any clear-cut changes
between ULR and CW-AFL patterns. This finding is consis-
tent with a report of Lai et al18 and shows that a typical CW
pattern is not always associated with CTI-AFL. In a recent
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important study by Tai et al,19 the ECG morphology appeared
to be dependent on the CS/LA activation sequence.
LA Atrial Flutter
Those with LA-AFL had a significantly higher incidence of
LA enlargement, atrial fibrillation, and longer tachycardia CL
compared with those with RA-AFL. Jais et al8 first reported
LA-AFL maps and pointed out a rather variegated pattern of
surface expression for the LA-AFL population.
LA Septal Circuit
Patients with LA septal circuit typically showed large,
usually positive waves in V1 with almost flat waves in
other leads. We suggest that this pattern might be caused
by a septal circuit with anterior-posterior forces projecting
on V1 and the cancellation of caudocranial forces. This
pattern was 100% sensitive for an LA septal circuit, but the
specificity of this pattern for any LA-AFL was only 64%
(P0.002).
Mitral Annulus AFL
Most of these patients showed prominent forces in V1/V2 with
diminished amplitude in the inferior leads. It is suggested that
a posterior LA scar allows for domination by anterior LA
forces. This constellation of findings might mimic CCW or
CW CTI-AFL, but the decreased amplitude of frontal plane
forces suggests an LA circuit (Table 2).
Posterior Wall Scar Circuits
This group showed the most variable surface ECG patterns.
The only possible distinguishing feature was the relatively
low-amplitude signals in the inferior leads. The voltage in
lead I was significantly greater in this group compared with
those with CCW CTI-AFL (0.91 vs 0.0050.4 mV;
P0.05; Table 2). Hence, low-amplitude inferior forces and
prominent, positive forces in lead I suggest a posterior wall
scar circuit.
Limitations
For most of those with RA-AFL, a detailed electroanatomic
map was unavailable; hence, our explanations require confir-
ECG Characteristics of Atypical Flutter 65
LA
LA Septal Mitral Posterior Wall
Circuit Annulus Macroreentry
(n11) (n3) (n8)
0.080.1 1.20.35 1.61
0 0.30.57 0.91
2.30.4 1.60.35 1.61.2
mation by more detailed studies. The data derived from this
study might not be an accurate indication of the incidence of
LA-AFL circuits. This is because some LA circuits could not
be completely mapped and thus, were not included in this
study.
Clinical Implications
Our studies for those with RA-AFL highlight the impor-
tance of entrainment mapping. We found instances of
atypical surface patterns that were CTI dependent and vice
versa. LA-AFL showed more inhomogeneous patterns. A
large-amplitude flutter (or P) wave in V1 associated with
flat, inferior P waves was pathognomonic of LA septal
circuit but was observed in other LA circuits. In addition,
those with LA-AFL had a tendency for a greater isoelectric
interval, which might reflect wide areas of slow
conduction.20
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 Surface Electrocardiographic Characteristics of Right and Left Atrial Flutter
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Circulation. 2003;108:60-66; originally published online June 30, 2003;

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