A New Electrocardiographic Algorithm to Differentiate Upper Loop Re-Entry From Reverse Typical Atrial Flutter Original Research Article

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 ≤ 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 ≤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.