ATRIAL FLUTTER

&
ATRIAL FIBRILLATION

MUHAMMAD ALI
PEDIATRIC CARDIOLOGY DIVISION

ATRIAL
FLUTTER
Description
The pacemaker lies in an ectopic focus, and circus
movement in the atrium is the mechanism of this
arrhythmia. Atrial flutter is characterized by an atrial rate
(F wave with sawtooth configuration) of about 300
beats/minute, a ventricular response with varying
degrees of block (e.g., 2:1, 3:1, 4:1), and normal QRS
complexes

Causes
Possible causes are structural heart disease with dilated
atria, myocarditis, previous surgery involving atria (the
Mustard or Senning procedure, Fontan operation, or
atrial septal defect repair), and digitalis toxicity
Significance
The ventricular rate determines eventual cardiac output;
a too-rapid ventricular rate may decrease cardiac output.
Atrial flutter usually suggests a significant cardiac
pathology.

Management
Digitalization is provided if the arrhythmia is not the result of digitalis
toxicity; digitalis increases the AV block and thereby slows the
ventricular rate. Propranolol (1 to 4 mg/kg per day orally in three or
four doses) may be added to digoxin
Recent reports suggest that amiodarone may be more effective than
digoxin in treating atrial flutter. One can start with a trial of digoxin
and, if digoxin fails, progress to amiodarone
Electric cardioversion may be required. Digitalis should be
discontinued for at least 48 hours before cardioversion.
Anticoagulation with warfarin is recommended before cardioversion
to prevent embolization
Rapid atrial pacing with a catheter in the esophagus or the right
atrium can be effective when cardioversion is contraindicated (e.g.,
digitalized patients)
Quinidine may prevent recurrence.

ATRIAL
FIBRILLATION
Description
The mechanism of this arrhythmia is circus movement,
as in atrial flutter. Atrial fibrillation is characterized by an
extremely fast atrial rate (f wave at a rate of 350 to 600
beats/minute) and an irregularly irregular ventricular
response with normal QRS complexes

Causes
Atrial fibrillation usually is associated with structural heart
disease, including dilated atria; myocarditis; digitalis
toxicity; or previous intra-atrial surgery
Significance
The rapid ventricular rate, in addition to the loss of
coordinated contraction of the atria and ventricles,
decreases the cardiac output, as occurs in atrial
tachycardia.
Atrial fibrillation usually suggests a significant cardiac
pathology.

Management
AF > 48 hours, anticoagulation warfarin for 3 weeks to prevent
systemic embolization of atrial thrombus. Anticoagulation is continued
for 4 weeks after the restoration of sinus rhythm. If cardioversion
cannot be delayed, heparin should be started, with subsequent oral
anticoagulation

Digoxin is provided to slow the ventricular rate. Propranolol (1 to 4

mg/kg per day orally in three or four doses) may be added
As a pharmacologic means of conversion, class I antiarrhythmic
agents (e.g., quinidine, procainamide, flecainide) and the class III
agent amiodarone may be used
In patients with chronic atrial fibrillation, anticoagulation with warfarin
should be considered to reduce the incidence of thromboembolism
Quinidine may prevent recurrence.

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