Circulation

CASES AND TRACES

Atrioventricular Conduction During
Atrial Flutter

ECG CHALLENGE Jasen L. Gilge , MD

A 59-year-old man with fatigue, dyspnea on exertion, and atrial flutter (AFL) pre- Eric N. Prystowsky, MD
sented for electrophysiology consultation. His cardiovascular examination and Benzy J. Padanilam, MD
echocardiogram were normal. The ECG is displayed in Figure 1. While considering
rate and rhythm control options, the ECG provided an important clue, and a de-
termination was made to proceed with a permanent pacemaker implantation first.
What finding on the ECG led to the decision against directly proceeding to rhythm
control options?
Please turn the page to read the diagnosis.
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Figure 1. Baseline ECG.

Atrial flutter with a ventricular rate of 55 bpm, right bundle-branch block, and left posterior fascicular block are noted.

© 2020 American Heart Association, Inc.

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Circulation. 2020;142:1783–1786. DOI: 10.1161/CIRCULATIONAHA.120.050257 November 3, 2020 1783

 Gilge et al
CASES AND TRACES
Figure 2. ECG with atrial flutter and constant 5:1 atrioventricular (AV) conduction.
The lead II rhythm strip at the bottom shows a fixed flutter wave to QRS interval, indicating the presence of atrioventricular conduction. The ECG was obtained
from a different patient to show the constant flutter to QRS complex intervals when atrioventricular conduction is present in contrast to the presenting rhythm
shown in Figure 1.
RESPONSE TO ECG CHALLENGE
A slow regular ventricular rhythm during AFL raises
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the question of whether it is AFL with fixed atrio-
ventricular conduction or AFL with underlying com-
plete heart block (CHB) and a junctional/ventricular
escape rhythm.1 The patient’s presenting ECG (fig-
ure  1) shows regular flutter waves and regular QRS
complexes but with varying intervals from flutter
wave to QRS complex. When the atrial and ventric-
ular rhythms are regular, a varying relationship be-
tween the 2 indicates dissociation of the 2 rhythms
and CHB. The right bundle-branch block and left
posterior fascicular block noted on the presenting
ECG can alert the clinician to cardiac conduction sys-
tem disease, although it does not indicate CHB. For
comparison, an ECG of a different patient with AFL
and 5:1 atrioventricular conduction with regular QRS
intervals is shown in Figure  2. The ventricular rates
are similar, but the constant intervals between the
QRS complexes and preceding flutter waves indicate
that the flutter waves conduct to the QRS complexes,
verifying atrioventricular conduction is present.
Mathematically, if flutter waves are regular and
QRS intervals are regular, they must keep a constant
relationship when atrioventricular conduction is pres-
ent and no relationship when conduction is absent
as shown in the ladder diagrams (Figure 3). AFL has
remarkably constant cycle lengths, as do junctional/
1784 November 3, 2020
ECG Challenge
ventricular escape rhythms; this allows for a quick
determination of presence or absence of atrioventric-
ular conduction on the surface ECG by applying the
aforementioned principles. An exception to this rule
would be isorhythmic dissociation of the flutter and
ventricular rhythms. Here, the dissociation of flutter
and QRS complexes will be evident when a longer
rhythm strip is examined. An accelerated junctional
or ventricular rhythm can lead to atrioventricular dis-
sociation without CHB during AFL or sinus rhythm
and should be considered when the ventricular rate
is relatively high.
Identifying the absence of atrioventricular conduc-
tion from the presenting surface ECG was important
in the decision-making process for the patient. He
underwent permanent pacemaker implantation first
for symptomatic bradycardia. An electrophysiology
study was also undertaken where CHB was noted,
again from the dissociation between the constant
atrial rhythm and constant ventricular rhythm (Fig-
ure  4). The escape rhythm was preceded by a His
bundle electrogram and normal His bundle to ventri-
cle (HV) interval, indicating a junctional escape from
the atrioventricular node or upper His bundle. Ven-
tricular escape rhythms would not be preceded by
His bundle electrograms, and low His/bundle-branch
sites of escape rhythm would show a short HV in-
terval. Entrainment from the cavotricsupid isthmus
resulted in a long postpacing interval indicating that
Circulation. 2020;142:1783–1786. DOI: 10.1161/CIRCULATIONAHA.120.050257
 Gilge et al ECG Challenge

CASES AND TRACES

Figure 3. Ladder diagrams.
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A, Atrial flutter with a constant 5:1 atrioventricular conduction. B, The corresponding ladder diagram of atrioventricular conduction. Note the consistent flutter
wave (F) to QRS interval. The ladder diagram is an oversimplification because it is not possible to determine which flutter wave is actually conducted to the ven-
tricle. However, clinically, when atrial and ventricular rhythms are regular, one can simply interrogate the interval between the QRS complexes and preceding flutter
wave. C, Atrial flutter with complete heart block and junctional escape. D, The corresponding ladder diagram. Note the variable flutter wave to QRS interval with
complete heart block. A indicates atrium; AVN, atrioventricular node; H, His bundle; and V, ventricle.

Figure 4. Intracardiac tracing during electrophysiology study.

Atrial intervals and ventricular intervals are regular and constant. Lack of association between atrial flutter signals (F) and the ventricular signals (V) indicates
complete heart block. The catheter at the His bundle location (HBED) shows a His (H) signal preceding every QRS, indicating a junctional focus of the escape
rhythm. H indicates His bundle, HBED, His bundle electrogram distal; HBEP, His bundle electrogram proximal; and RVD, right ventricle distal.

Circulation. 2020;142:1783–1786. DOI: 10.1161/CIRCULATIONAHA.120.050257 November 3, 2020 1785

 Gilge et al ECG Challenge

the flutter was not typical. The patient’s symptoms Affiliation

CASES AND TRACES

improved with rate-responsive permanent ventricular Department of Internal Medicine, Division of Cardiology, Ascension St Vincent,
Indianapolis, IN.
pacing, and restoration of sinus rhythm was not at-
tempted based on patient preference.
Disclosures
None.

‍ARTICLE INFORMATION
Correspondence REFERENCE
Jasen L. Gilge, MD, 8333 Naab Road #400, Indianapolis, IN 46260. Email jasen. 1. Newcombe CP, De Souza D, Towers RH. Atrial flutter with complete heart
gilge@ascension.org block. Br Heart J. 1960;22:691–694. doi: 10.1136/hrt.22.5.691
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1786 November 3, 2020 Circulation. 2020;142:1783–1786. DOI: 10.1161/CIRCULATIONAHA.120.050257