Abdala-Lizarraga Julian, Quesada-Ocete Javier, Quesada-Ocete Blanca, Jiménez-Bello Javier, Quesada Aurelio
School of Doctorate, Catholic University of Valencia San Vicente Mártir, 46001 Valencia, Spain.
Arrhythmia Unit, Cardiology Service, General University Hospital Consortium of Valencia, 46014 Valencia, Spain.
Rev Cardiovasc Med. 2024 Jan 9;25(1):11. doi: 10.31083/j.rcm2501011. eCollection 2024 Jan.
The demonstration of a peritricuspid circular movement with a zone of slow conduction in the cavotricuspid isthmus, together with the high efficacy of linear ablation and widely accepted acute endpoints, has established typical flutter as a disease with a well-defined physiopathology and treatment. However, certain aspects regarding its deeper physiopathology, ablation targets, and methods for verifying the results remain to be clarified. While current research efforts have primarily been focused on the advancement of effective ablation techniques, it is crucial to continue exploring the intricate electrophysiological, ultrastructural, and pharmacological pathways that underlie the development of atrial flutter. This ongoing investigation is essential for the development of targeted preventive strategies that can act upon the specific mechanisms responsible for the initiation and maintenance of this arrhythmia. In this work, we will discuss less ascertained aspects alongside the most widely recognized general data, as well as the most recent or less commonly used contributions regarding the electrophysiological evaluation and ablation of typical atrial flutter. Regarding electrophysiological characteristics, one of the most intriguing findings is the presence of low voltage zones in some of these patients together with the presence of a functional, unidirectional line of block between the two vena cava. It is theorized that episodes of paroxysmal atrial fibrillation can trigger this line of block, which may then allow the onset of stable atrial flutter. Without this, the patient will either remain in atrial fibrillation or return to sinus rhythm. Another of the most important pending tasks is identifying patients at risk of developing post-ablation atrial fibrillation. Discriminating between individuals who will experience a complete arrhythmia cure and those who will develop atrial fibrillation after flutter ablation, remains essential given the important prognostic and therapeutic implications. From the initial X-ray guided linear cavotricuspid ablation, several alternatives have arisen in the last decade: electrophysiological criteria-directed point applications based on entrainment mapping, applications directed by maximum voltage criteria or by wavefront speed and maximum voltage criteria (omnipolar mapping). Electro-anatomical navigation systems offer substantial support in all three strategies. Finally, the electrophysiological techniques to confirm the success of the procedure are reviewed.
三尖瓣环周围存在圆周运动且腔静脉-三尖瓣峡部有缓慢传导区域的表现，加上线性消融的高效性以及广泛认可的急性终点，已将典型心房扑动确立为一种具有明确病理生理学和治疗方法的疾病。然而，关于其更深层次的病理生理学、消融靶点以及结果验证方法的某些方面仍有待阐明。虽然目前的研究主要集中在有效消融技术的进步上，但继续探索心房扑动发生发展背后复杂的电生理、超微结构和药理途径至关重要。这项持续的研究对于制定有针对性的预防策略至关重要，这些策略可以作用于导致这种心律失常发生和维持的特定机制。在这项工作中，我们将讨论不太确定的方面以及最广泛认可的一般数据，以及关于典型心房扑动的电生理评估和消融的最新或不太常用的研究成果。关于电生理特征，最引人入胜的发现之一是其中一些患者存在低电压区，同时在两条腔静脉之间存在功能性单向阻滞线。理论上，阵发性心房颤动发作可触发这条阻滞线，进而导致稳定的心房扑动发作。否则，患者将要么持续处于心房颤动状态，要么恢复窦性心律。另一个最重要的待解决任务是识别有消融后发生心房颤动风险的患者。鉴于其重要的预后和治疗意义，区分哪些患者将实现心律失常完全治愈，哪些患者在心房扑动消融后会发生心房颤动仍然至关重要。从最初的X线引导下腔静脉-三尖瓣线性消融开始，在过去十年中出现了几种替代方法：基于拖带标测的电生理标准指导的点消融、基于最大电压标准或波前速度和最大电压标准（全极标测）指导的消融。在所有这三种策略中，电解剖导航系统都提供了有力支持。最后，对确认手术成功的电生理技术进行了综述。
