How well do we understand the re-entrant right atrial (RA) activation during isthmus-dependent AFL?

Figure 1. A schema of the macro-reentrant circuit of isthmus-dependent atrial flutter (AFL) in right atrium (RA). In either rotation, counterclockwise (CCW) or clockwise (CW), the activation wave front could propagate either anterior (A) or posterior (B) to the coronary sinus (CS).

IVC, inferior vena cava; TV, tricuspid valve The question is, does a large RA circuit such as typical AFL require a specific zone of slow conduction so that the circuit length (wavelength, a product of refractory period and conduction velocity5) can fit the anatomical pathway? Lately, different groups have mapped the RA circuit of human AFL in great detail using multiple endocardial recordings,6,7 intra-cardiac echocardiography,8 electro-anatomical CARTO,9 64-electrode basket catheter,10 non-contact EnSite11 and body surface mapping.12 There is a general agreement between these studies and other protocols,13,14 measuring conduction velocity directly, regarding slow isthmus conduction during AFL. This ... more.

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