title: Separating non-isthmus- from isthmus-dependent atrial flutter using wavefront variability.
abstract: OBJECTIVE
  The aim of this study was to separate isthmus-dependent atrial flutter (IDAFL) from non-isthmus-dependent atrial flutter (NIDAFL) from the electrocardiogram (ECG) based on functional differences.
  
  
  BACKGROUND
  The ECG analyses of F-wave shape suboptimally separate NIDAFL from IDAFL. The authors hypothesized that anatomic and functional differences may result in greater wavefront variability in NIDAFL than IDAFL, allowing their separation. The authors tested this hypothesis in patients undergoing ablation for atrial flutter using a novel ECG algorithm to detect subtle F-wave variability, validated by intracardiac measurements.
  
  
  METHODS
  In 62 patients (23 NIDAFL, 39 IDAFL) ECG atrial wavefronts were represented as correlations of an F-wave template to the ECG over time. Correlations in orthogonal ECG lead-pairs were plotted at each time point to yield loops reflecting temporal and spatial regularity in each plane. The ECG analyses were compared with intracardiac standard deviations of: 1) atrial electrograms (temporal variability), and 2) bi-atrial activation time differences (spatial variability).
  
  
  RESULTS
  Atrial ECG temporospatial loops were reproducible in IDAFL, but varied in NIDAFL (p < 0.01) suggesting greater variability that correctly classified IDAFL (39 of 39 cases) from NIDAFL (22 of 23 cases; p < 0.001). Intra-atrial mapping confirmed greater temporal variability for NIDAFL versus IDAFL, in lateral (p < 0.01) and septal (p = 0.03) right atrium, and proximal (p = 0.02) and distal (p < 0.01) coronary sinus. Spatial variability was greater in NIDAFL than IDAFL (p = 0.02).
  
  
  CONCLUSIONS
  Greater cycle-to-cycle atrial wavefront variability separates NIDAFL from IDAFL and is detectable from the ECG using temporospatial analyses. These results have implications for guiding ablation and support the concept that IDAFL and NIDAFL lie along a spectrum of intracardiac organization.
authors.affiliation: University of California and Veterans Administration Medical Centers, San Diego, California 92161, USA. snarayan@ucsd.edu
authors.forename: Sanjiv M
authors.initials: SM
authors.lastname: Narayan
authors.forename: Alborz
authors.initials: A
authors.lastname: Hassankhani
authors.forename: Gregory K
authors.initials: GK
authors.lastname: Feld
authors.forename: Valmik
authors.initials: V
authors.lastname: Bhargava
mesh_terms: D000465:Algorithms; D001282:Atrial Flutter / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D017115:Catheter Ablation; D003937:Diagnosis, Differential; D004562:Electrocardiography; D006801:Humans; D008875:Middle Aged