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Rapid atrial septal oscillation — A new two-dimensional echocardiographic sign in atrial flutter
International Journal of Cardiology 167 (2013) e10–e11
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Rapid atrial septal oscillation — A new two-dimensional echocardiographic sign in atrial flutter Poh Shuan Daniel Yeo a,⁎, Quek Wei Yong b a b
Heart Failure Service, Department of Cardiology, Tan Tock Seng Hospital, Singapore Department of Cardiology, Tan Tock Seng Hospital, Singapore
a r t i c l e
i n f o
Article history: Received 1 January 2013 Accepted 21 January 2013 Available online 7 March 2013 Keywords: Atrial flutter New echocardiographic sign Rapid atrial septal oscillation
The electrocardiographic representation of atrial flutter is welldescribed [1,2]. However, echocardiographic visualization of the progress of the atrial flutter wave in the atria has not been previously described. We present the first recorded echocardiographic manifestation of atrial flutter in the form of a rapidly oscillating atrial septum. A 76 year old male with chronic hypertension was admitted for elective right hemicolectomy for colonic carcinoma. A pre-operative ECG had shown normal sinus rhythm. The operation was uneventful but he developed sepsis on the third post-operative day. ECG showed new-onset atrial flutter with 4:1 atrio-ventricular block (Fig. 1, panel A). Echocardiography showed a mobile inter-atrial septum (IAS) (excursion
⁎ Corresponding author at: Department of Cardiology, Level 3, TTSH Annex, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. Tel.: +65 63577831; fax: +65 63526682. E-mail address: [email protected] (P.S.D. Yeo). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.270
9 mm) oscillating rapidly at a rate of 4 Hz, corresponding to the flutter rate (Video). This is consistent with a macro-re-entrant circuit starting from the right atrium (RA). This causes an initial right atrial contraction and thus bulge of the IAS to the left atrium (LA) (Fig. 1, panel B), which is followed next by left atrial contraction and bulging of the IAS to the RA as the depolarization spreads passively to the LA (Fig. 1, panel C). The regular and rapid IAS oscillation suggests it moves in concert with the flutter wave depolarization, and when coupled with the ECG appearance, is consistent with a reverse typical atrial flutter [1]. The patient recovered fully with standard anti-microbial and supportive therapy and remains well at 2 years with no clinical recurrence of atrial flutter or carcinoma. This is the first echocardiographic visualization of atrial flutter manifested as a rapidly oscillating atrial septum. This report complies with the ethical standards required by the Journal. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2013.01.270.
References [1] Waldo AL. Treatment of atrial flutter. Heart 2000;84:227–32. [2] Tchou P. Chapter 64: Atrial Flutter. In: Topol Eric J, editor. Textbook of cardiovascular medicine. 3rd ed. Philadelphia, USA: Lippincott Williams & Wilkins; 2007. p. 1069–75.
P.S.D. Yeo, Q.W. Yong / International Journal of Cardiology 167 (2013) e10–e11
e11
A
B
C
Fig. 1. ECG showing atrial flutter (panel A). Inter-atrial septum (arrow) oscillating to the left atrium (panel B) and back to the right atrium (panel C).
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Rapid atrial septal oscillation — A new two-dimensional echocardiographic sign in atrial flutter Poh Shuan Daniel Yeo a,⁎, Quek Wei Yong b a b
Heart Failure Service, Department of Cardiology, Tan Tock Seng Hospital, Singapore Department of Cardiology, Tan Tock Seng Hospital, Singapore
a r t i c l e
i n f o
Article history: Received 1 January 2013 Accepted 21 January 2013 Available online 7 March 2013 Keywords: Atrial flutter New echocardiographic sign Rapid atrial septal oscillation
The electrocardiographic representation of atrial flutter is welldescribed [1,2]. However, echocardiographic visualization of the progress of the atrial flutter wave in the atria has not been previously described. We present the first recorded echocardiographic manifestation of atrial flutter in the form of a rapidly oscillating atrial septum. A 76 year old male with chronic hypertension was admitted for elective right hemicolectomy for colonic carcinoma. A pre-operative ECG had shown normal sinus rhythm. The operation was uneventful but he developed sepsis on the third post-operative day. ECG showed new-onset atrial flutter with 4:1 atrio-ventricular block (Fig. 1, panel A). Echocardiography showed a mobile inter-atrial septum (IAS) (excursion
⁎ Corresponding author at: Department of Cardiology, Level 3, TTSH Annex, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. Tel.: +65 63577831; fax: +65 63526682. E-mail address: [email protected] (P.S.D. Yeo). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.270
9 mm) oscillating rapidly at a rate of 4 Hz, corresponding to the flutter rate (Video). This is consistent with a macro-re-entrant circuit starting from the right atrium (RA). This causes an initial right atrial contraction and thus bulge of the IAS to the left atrium (LA) (Fig. 1, panel B), which is followed next by left atrial contraction and bulging of the IAS to the RA as the depolarization spreads passively to the LA (Fig. 1, panel C). The regular and rapid IAS oscillation suggests it moves in concert with the flutter wave depolarization, and when coupled with the ECG appearance, is consistent with a reverse typical atrial flutter [1]. The patient recovered fully with standard anti-microbial and supportive therapy and remains well at 2 years with no clinical recurrence of atrial flutter or carcinoma. This is the first echocardiographic visualization of atrial flutter manifested as a rapidly oscillating atrial septum. This report complies with the ethical standards required by the Journal. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2013.01.270.
References [1] Waldo AL. Treatment of atrial flutter. Heart 2000;84:227–32. [2] Tchou P. Chapter 64: Atrial Flutter. In: Topol Eric J, editor. Textbook of cardiovascular medicine. 3rd ed. Philadelphia, USA: Lippincott Williams & Wilkins; 2007. p. 1069–75.
P.S.D. Yeo, Q.W. Yong / International Journal of Cardiology 167 (2013) e10–e11
e11
A
B
C
Fig. 1. ECG showing atrial flutter (panel A). Inter-atrial septum (arrow) oscillating to the left atrium (panel B) and back to the right atrium (panel C).