Transcript clinical conference - Advocatehealth.com

CLINICAL
CONFERENCE
By Faizul Haque
Date Presented: 12/4/2007
Department of Cardiology
University of Illinois at Chicago
CASE
• 58 y/o F who had initially presented to
outside hospital for severe palpitations
+ lightheadedness:
– she states the sx of palpitations started within
2d prior to recent admission: she has had
intermittent hx of palpitations since 2003
– she has had some associated LH: denies any
syncopal episodes
– patient denies any CP/SOB/DOE per review
– Patient referred to UIC EP for further
evaluation/management
Past Hx
• pMHx/pSurghx:
– Hx of mitral stenosis + severe MR
• MVR+TV repair in 4/2004 at outside hospital
• Redo bioprosthetic MVR + TV repair recently in
8/07 at outside hospital
– Hx of HTN
– Hx of depression
– Hx of HL
Physical Exam:
•
•
•
•
O: V/S – 97.1 – 104/60 - ~100bpm
Gen: NAD; resting upright
Neck: JVP at 6cmH20
Chest: b/l CTA; no wheezes or crackles
noted
• CV: rr nl s1s2 no s3s4 noted; no RV
impulse
• Abd: +BS
• Ext: no b/l LEE noted
Med Hx:
• Medications: current
– Metoprolol 12.5mg BID
– ASA 325mg qD
– Lasix 20mg qD
– Zocor 20mg qHS
coumadin 5mg + 2.5mg alternating qD
Clinical Questions:
• TTE: 11/07
– 1. Left atrium mildly dilated: 4.41cm
– 2. Global normal LV function: EF 50-55%
– 3. Global normal RV size + function
– 4. Peak TV TR at 2.7m/sec, PA 38mmHg
Atrial Flutter: Basics
• Prototypic macroreentrant atrial rhythm
• Typical/atypical atrial flutter:
• Reentrant rhythm in the R atrium constrained
anteriorly by the tricuspid annulus and posteriorly
by the crista terminalis and eustachian ridge
• Typical atrial flutter usually defined by
counterclockwise versus clockwise rotation along
the macroreentrant circuit
Hx
Aflutter: ECG Criteria
• Typical atrial flutter [Type I]
• Identically recurring sawtooth flutter [F] waves best
visualized in II, III, AVf + V1
• Inverted [negative] flutter waves in II, III, AVf due to
counterclockwise reentry
• Upright [positive] flutter waves in II, III, AVf present
during clockwise reentry
• Involves the cavotricuspid isthmus [CTI]
• Atypical atrial flutter
• Not involving CTI: could be from prior atrial
surgery/ablation, idiopathic fibrosis, L atrial
origination around the mitral annulus
Clinical Questions:
• Which patients are considered ideal
candidates for catheter-based atrial flutter
ablation?
• Ideally patients with cavotricuspid isthmus
dependent atrial flutter or typical atrial flutter as
opposed to atypical CTI-independent scenarios
Aflutter Ablation
Clinical Questions:
Clinical Questions: