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.

THANK YOU