A new electrocardiographic algorithm to differentiate upper loop re-entry from reverse typical atrial flutter

J Am Coll Cardiol. 2005 Aug 2;46(3):524-8. doi: 10.1016/j.jacc.2005.04.049.


Objectives: This study was performed to differentiate upper loop re-entry (ULR) from reverse typical atrial flutter (AFL).

Background: Right atrial ULR and reverse typical AFL have different mechanisms and ablation strategies, but similar electrocardiographic characteristics.

Methods: This study included 26 patients with reverse typical AFL and 20 patients with ULR. The noncontact mapping system (EnSite-3000, Endocardial Solutions, St. Paul, Minnesota) was used to confirm diagnosis and guide successful radiofrequency ablation. Flutter wave polarity and amplitude in the 12-lead surface electrocardiogram were determined by two independent electrophysiologists.

Results: The flutter wave polarity in leads I and aVL was significantly different between the reverse typical AFL and ULR groups (p < or = 0.001). Voltage measurement revealed significant differences between reverse typical AFL and ULR in leads I, II, aVR, aVF, V1, and V2 (p < 0.001). A new diagnostic algorithm based on negative or isoelectric/flat flutter wave polarity and amplitude < or =0.07 mV in lead I was useful for diagnosis of ULR, with an accuracy of 90% to 97%, a sensitivity of 82% to 100%, and a specificity of 95%.

Conclusions: Polarity and voltage measurement of flutter wave in lead I can differentiate reverse typical AFL from ULR.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Algorithms*
  • Atrial Flutter / diagnosis*
  • Atrial Flutter / mortality
  • Atrial Flutter / surgery
  • Body Surface Potential Mapping*
  • Catheter Ablation / methods*
  • Cohort Studies
  • Electrocardiography / methods*
  • Electrophysiologic Techniques, Cardiac / methods
  • Female
  • Humans
  • Male
  • Middle Aged
  • Observer Variation
  • ROC Curve
  • Retrospective Studies
  • Risk Assessment
  • Sensitivity and Specificity
  • Survival Analysis
  • Treatment Outcome