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cardio.atrial_flutter.atypical-left-atrial.v1

Atypical / scar-mediated / left atrial flutter

cardiologyacutechronicadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.atrial_flutter.v1 — narrowed to atypical / scar-mediated / left atrial macroreentrant flutter (NOT using cavotricuspid isthmus). Substrate includes post-PVI, post-CABG, post-MAZE, post-valve, post-transplant, congenital HD, or RA non-CTI scar. Inherits AC + acute rate/rhythm management from parent; specializes the 3D electroanatomic mapping ablation pathway, scar-substrate AAD selection (amiodarone first-line; flecainide CONTRAINDICATED per CAST), mixed AF/AFL management, and post-LA-ablation atrioesophageal fistula surveillance. Ablation success rate 60–80% (lower than CTI) per Aliot 2009 (PMID 19324313); 3D electroanatomic mapping required to identify circuit. Mixed AF/AFL coexistence is the RULE rather than exception — lifelong AC typical even after successful ablation. Post-LA-ablation atrioesophageal fistula incidence ~0.1–0.25% with ~80% mortality — HIGHER RISK than CTI ablation; warning signs (fever + chest pain + neuro deficit weeks 2–6) require emergency surgical evaluation. Amiodarone first-line AAD given structural HD substrate; flecainide/propafenone CONTRAINDICATED per CAST (PMID 1900101). Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (3)

  • imaging
    Flutter waves NOT meeting typical CTI criteria — positive in II/III/aVF, prominent V1, variable axis
    atypical_flutter_morphology_on_ecg
  • history
    Recurrent atrial flutter after prior AF ablation (PVI), MAZE, CABG, valve, or transplant — scar-mediated reentry
    recurrent_aflutter_post_pvi_or_cardiac_surgery
  • symptom
    Palpitations / dyspnea / fatigue in patient with prior left atrial intervention or congenital heart disease
    palpitations_in_post_cardiac_surgery_patient

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    CHA2DS2-VASc + ablation candidacy
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 with flutter RVR → emergent DCCV 100–200 J biphasic (atypical may need higher energy than typical)
  • hrrequired
    vital • used at CONTEXT
    Conduction ratio variable (1:1, 2:1, 3:1) — atypical flutter has more variable AV ratios
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Atypical morphology — positive flutter waves II/III/aVF, prominent V1 (mitral isthmus, roof-dependent, or LA-scar circuit) — Saoudi 2001 (PMID 11428013); Aliot 2009 (PMID 19324313)
  • prior_pvi_maze_cabg_valve_transplantrequired
    history • used at CONTEXT
    Identifies scar substrate; ~30–50% of post-PVI patients develop atypical LA flutter (Patel 2008 PMID 18272844)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    DOAC + AAD dosing; contrast for 3D mapping/ablation
  • tshrequired
    lab • used at INITIAL_WORKUP
    Reversible cause screen; amiodarone-induced thyroid dysfunction common in this population
  • tterequired
    imaging • used at INITIAL_WORKUP
    LA size, EF, valvular function, prior surgical anatomy review; LA appendage thrombus screen pre-ablation
  • tee_or_cardiac_ct_pre_ablation
    imaging • used at TREATMENT
    LA appendage thrombus exclusion + chamber anatomy for 3D mapping — required pre-LA ablation
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AC indication identical to AF
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED + ablation peri-procedure bleed risk

12-phase flow (11)

  1. 1FRAME
    Confirm atypical (NON-CTI) flutter — morphology not meeting typical sawtooth criteria + history of LA scar substrate (post-PVI, post-CABG, post-MAZE, post-valve, congenital HD); often coexists with AF
    inputs: ecg_12_lead, prior_pvi_maze_cabg_valve_transplant
    advance: Atypical morphology + scar substrate confirmed
  2. 2ENTRY
    Palpitations / dyspnea / fatigue / syncope / incidental telemetry, often in post-cardiac-surgery or post-PVI patient
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Prior PVI / MAZE / CABG / valve / transplant / congenital surgical repair; structural HD; prior AAD trials (often refractory); current meds + AVN-blocker review
    inputs: hr, cha2ds2_vasc_factors, bleeding_history, prior_pvi_maze_cabg_valve_transplant
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability (SBP <90, pulmonary edema, ischemia, AMS) → synchronized DCCV 100–200 J biphasic now (atypical often needs higher energy than typical)
    inputs: sbp
    actions: tachycardia
    advance: Stable or cardioverted
  5. 5INITIAL_WORKUP
    ECG, TSH, BMP/Mg, creatinine, CBC, BNP, TTE — baseline + structural anatomy review
    inputs: ecg_12_lead, tsh, creatinine_egfr, tte
    actions: panel.cardiac, panel.thyroid, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    TEE or cardiac CT to exclude LA appendage thrombus before any planned ablation; concomitant AF surveillance (Holter — high overlap); chest-pain comorbid → acs_pathway
    inputs: tee_or_cardiac_ct_pre_ablation
    actions: acs_pathway, afib_new_onset
    advance: Branch resolved
  7. 7RISK_STRATIFICATION
    CHA2DS2-VASc (AC indication identical to AF) + HAS-BLED + eGFR for DOAC + AAD dose
    inputs: cha2ds2_vasc_factors, bleeding_history
    advance: Risk tier documented
  8. 8TREATMENT
    Acute: rate control (BB or non-DHP CCB) + amiodarone often required given structural HD; ibutilide less effective for atypical (lower conversion rate); often need DCCV. Long-term: 3D electroanatomic mapping + ablation (success 60–80%, lower than CTI); AC lifelong given high mixed AF/AFL coexistence — ACC/AHA 2024 (PMID 38753446)
    inputs: hr, creatinine_egfr
    advance: Acute strategy + AC + EP referral booked for 3D mapping
  9. 9DISPOSITION
    Admit if unstable, new HF, AAD initiation (esp dofetilide REMS), recent ablation, or peri-ablation bridging; discharge if rate-controlled with AC and EP referral
    advance: Disposition documented
  10. 10MONITORING
    Telemetry; QTc on dofetilide / sotalol / amiodarone; post-ablation observation for groin hematoma, tamponade, atrioesophageal fistula (LA ablation higher risk than CTI); AC adherence
    inputs: ecg_12_lead
    advance: Monitoring orders documented
  11. 11FOLLOWUP
    EP for 3D mapping ablation; cardiology q3–6 mo; AC continuation per CHA2DS2-VASc (lifelong given mixed AF/AFL); lifestyle (alcohol, weight, OSA); post-ablation 4-week ECG + Holter at 3/6/12 mo for AF screen
    advance: Follow-up booked + ablation pathway entered