This handout is for atrial flutter in adult unrepaired/late-repaired atrial septal defect (ra volume overload → cti macroreentry). Your care team identified this based on: new atrial flutter / palpitations in adult with known unrepaired or late-repaired secundum asd — ra volume-overload substrate + cti macroreentry.
Other reasons your team may use this plan: atrial flutter on ecg with rv volume-overload pattern (rbbb or rsr' v1, right axis, ra enlargement) — undiagnosed asd or known asd presenting with arrhythmia; palpitations, dyspnea on exertion, or reduced exercise tolerance in adult with systolic flow murmur + fixed split s2 → undiagnosed asd + new afl; tte shows secundum asd with ra + rv dilation + l→r shunt + atrial flutter on telemetry — combined structural + arrhythmia substrate confirmed.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| metoprolol_tartrate | 5 mg IV q5min × 3 then 25-50 mg PO BID | IV/PO | IV q5min × 3 → PO BID | AVN slowing for ASD-related AFL — ACC/AHA 2024 (PMID 38753446); preferred over non-DHP CCB if RV dysfunction or pulm HTN |
| metoprolol_succinate | 25-50 mg PO daily; titrate | PO | daily | Long-acting BB bridge to combined closure + CTI ablation — ACC/AHA 2024 |
| amiodarone | 150 mg IV over 10 min then 1 mg/min × 6 h then 0.5 mg/min × 18 h; 200 mg PO daily maintenance | IV/PO | load + daily | Most efficacious AAD bridge to combined procedure given structural substrate; pulm/thyroid/hepatic toxicity monitoring — ACC/AHA 2024 (PMID 38753446) |
| dofetilide | 125-500 mcg PO BID per CrCl (REMS — inpatient initiation) | PO | BID | Alternative to amiodarone; dofetilide REMS — must be initiated inpatient with QTc + CrCl monitoring — ACC/AHA 2024 (PMID 38753446) |
| apixaban | 5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) | PO | BID | AC same as AF; lifelong AC typical given persistent RA substrate post-closure — ACC/AHA 2024 Class I (PMID 38753446); ARISTOTLE (PMID 21870978); Khairy 2010 GUCH-AF (PMID 20660806) |
| rivaroxaban | 20 mg with food (15 mg if CrCl 15-50) | PO | once daily | X-VeRT (PMID 24837375); peri-CV / peri-procedural strategy; ENGAGE-AF (PMID 24251369) |
| dabigatran | 150 mg BID (110 mg BID if age ≥75 or CrCl 30-50 in EU labelling) | PO | BID | Alternative DOAC — reversible with idarucizumab if peri-procedural bleeding |
| warfarin | INR 2-3 | PO | daily | Mechanical valve / severe MS — only warfarin — ACC/AHA 2024 |
| aspirin | 81 mg daily lifetime post-device closure; 162-325 mg load if pre-procedure | PO | daily lifetime post-closure | AHA/ACC 2018 ACHD (PMID 30121239) — ASA lifelong post-device closure for endothelialization + late device-related thrombus prevention |
| clopidogrel | 300 mg load → 75 mg daily × 1-6 mo per device | PO | daily × 1-6 mo | AHA/ACC 2018 ACHD (PMID 30121239) — DAPT 1-6 mo per device label for endothelialization period; resumes single-agent + AC if AC indicated |
Plan: ASD-related atrial flutter — rate control + AC + CTI ablation Class I + CONCURRENT ASD device closure if hemodynamically significant — ACC/AHA 2024 (Joglar PMID 38753446); AHA/ACC 2018 ACHD (Stout PMID 30121239)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
ACHD clinic + EP at 4 weeks post-procedure with 12-lead + Holter; AC continuation lifelong if persistent RA enlargement (substrate persistence — Silversides 2004 PMID 15036666); device endothelialization period 6 months — DAPT 1-6 mo per device + ASA lifetime; lifestyle (alcohol, weight, OSA per LEGACY); 3, 6, 12-month Holter; transition pediatric ACHD → adult ACHD if not yet established
Guideline: 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar Circulation 2024 PMID 38753446); 2018 AHA/ACC Adult Congenital Heart Disease Guideline (Stout PMID 30121239); ESC 2020 ACHD Guideline (Baumgartner PMID 32860412)