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cardio.atrial_flutter.post-pvi-iatrogenic.v1

Iatrogenic post-PVI atypical LA flutter (gap-related macroreentry)

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Phase E iatrogenic-substrate variant of cardio.atrial_flutter.v1 — narrowed to atypical macroreentrant LA flutter occurring 1-12 months post-PVI (post-blanking-period early recurrence window per HRS 2017 PMID 28506916). Mechanism: gap-related macroreentry through recovered conduction across prior PVI ablation lines, producing mitral-isthmus, LA roof, or perimitral circuits. Differs from cardio.atrial_flutter.atypical-left-atrial.v1 (de-novo substrate post-CABG/MAZE/valve/no intervention) and cardio.atrial_flutter.cardioversion-failed.v1 (outcome-defined refractory phenotype regardless of substrate). Definitive treatment: REDO 3D electroanatomic mapping ablation with gap targeting + linear lesion completion (mitral isthmus line, LA roof line) — Calkins 2017 (PMID 28506916); Chae 2007 (PMID 17698994). Combined PVI completion + AT ablation often needed at redo if PV reconnection documented. AC continuity: uninterrupted DOAC during redo per RE-CIRCUIT (PMID 28530171) and VENTURE-AF (PMID 25975659); lifelong AC typical given mixed AF/AFL coexistence post-PVI. Atrioesophageal fistula risk HIGHER with mitral isthmus line than CTI; warning signs (fever + chest pain + neuro deficit weeks 2-6) require emergency surgical evaluation. Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (5)

  • history
    Atrial arrhythmia recurrence 1-12 months after PVI for AF — post-blanking-period (HRS 2017 PMID 28506916) early recurrence window
    recurrent_atrial_arrhythmia_1_to_12_mo_post_pvi
  • imaging
    ECG atypical flutter morphology (positive II/III/aVF, prominent V1, mitral-isthmus or roof-circuit pattern) in patient with prior PVI
    atypical_flutter_morphology_in_post_pvi_patient
  • symptom
    Palpitations / dyspnea / fatigue / reduced exercise tolerance after recent (1-12 mo) PVI for AF
    palpitations_dyspnea_in_post_pvi_patient
  • imaging
    Organised atrial tachycardia (regular ventricular response with discrete P/F waves) on post-PVI Holter or wearable
    organized_atrial_tachycardia_on_post_pvi_holter
  • history
    Index PVI procedure documented incomplete linear lesions (mitral isthmus, LA roof) or known PV reconnection on follow-up — anatomic substrate for gap-related macroreentry
    incomplete_pvi_lines_documented_at_index_procedure

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    CHA2DS2-VASc + redo ablation candidacy + life expectancy for risk-benefit
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 with iatrogenic 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 post-PVI flutter often has slower flutter rates (200-260 bpm) than typical CTI (250-300) due to large reentrant circuit length
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Atypical morphology — mitral-isthmus flutter often positive in II/III/aVF + isoelectric/notched in V1 OR roof-dependent flutter has variable polarity; CRITICAL discriminator from sinus rhythm at slower rates — Patel 2008 (PMID 18272844)
  • prior_pvi_procedure_date_and_lesion_setrequired
    history • used at CONTEXT
    Anchors substrate; lesion set (PVI alone vs PVI + roof line vs PVI + mitral isthmus) directly predicts circuit type — Chae 2007 (PMID 17698994)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    DOAC + AAD dosing; contrast for redo 3D mapping/ablation
  • tshrequired
    lab • used at INITIAL_WORKUP
    Reversible cause screen; amiodarone-induced thyroid dysfunction common from post-PVI bridging amio
  • tterequired
    imaging • used at INITIAL_WORKUP
    LA size + EF + valvular function + post-ablation pericardial effusion screen; mitral annulus assessment for mitral-isthmus circuit
  • tee_or_cardiac_ct_pre_redo_ablation
    imaging • used at TREATMENT
    LA appendage thrombus exclusion + chamber anatomy + PV ostia for 3D mapping at redo — required if AC <3 wk uninterrupted (HRS 2017 PMID 28506916)
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AC indication identical to AF; lifelong typical post-PVI given mixed AF/AFL substrate
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED + redo-ablation peri-procedure bleed risk
  • index_pvi_complications_or_reconnection_data
    history • used at CONTEXT
    Prior PV reconnection on imaging/EP follow-up identifies gap location; informs redo strategy

12-phase flow (11)

  1. 1FRAME
    Iatrogenic atypical flutter from gap-related macroreentry 1-12 mo post-PVI (post-blanking window per HRS 2017). Three dominant circuits: mitral-isthmus, LA roof, perimitral. Redo ablation with gap targeting + linear lesion completion is definitive — Calkins 2017 (PMID 28506916)
    inputs: ecg_12_lead, prior_pvi_procedure_date_and_lesion_set
    advance: Post-PVI substrate + atypical morphology confirmed
  2. 2ENTRY
    Recurrent palpitations / dyspnea / fatigue / reduced exercise tolerance 1-12 mo post-PVI; ED, EP clinic, telemetry, or wearable detection
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Index PVI date + lesion set + acute success vs reconnection at follow-up; AAD bridge regimen post-PVI; AC continuity (interruption is a thrombosis trigger); structural HD; lifestyle modifiables (alcohol, weight, OSA — recurrence drivers)
    inputs: hr, cha2ds2_vasc_factors, bleeding_history, prior_pvi_procedure_date_and_lesion_set
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability (SBP <90, pulmonary edema, ischemia, AMS) → synchronized DCCV 100-200 J biphasic now (atypical may need higher energy); pre-excited 1:1 conducted (rare without WPW) → AVN-blocker AVOIDANCE + procainamide/DCCV
    inputs: sbp
    actions: tachycardia
    advance: Stable or cardioverted
  5. 5INITIAL_WORKUP
    ECG, TSH, BMP/Mg, creatinine, CBC, BNP, TTE — baseline + structural anatomy + pericardial assessment
    inputs: ecg_12_lead, tsh, creatinine_egfr, tte
    actions: panel.cardiac, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    TEE or cardiac CT to exclude LA appendage thrombus before redo ablation; concomitant AF surveillance via Holter (mixed AF/AFL is rule); chest-pain comorbid → acs_pathway routing
    inputs: tee_or_cardiac_ct_pre_redo_ablation
    actions: acs_pathway, afib_new_onset
    advance: Branch resolved
  7. 7RISK_STRATIFICATION
    CHA2DS2-VASc (AC indication identical to AF; lifelong typical given mixed substrate) + HAS-BLED + eGFR for DOAC + AAD dose + redo ablation candidacy
    inputs: cha2ds2_vasc_factors, bleeding_history
    advance: Risk tier documented
  8. 8TREATMENT
    Acute: rate control (BB or non-DHP CCB if EF preserved) + amiodarone often required given structural substrate; ibutilide less effective for atypical (lower conversion). Definitive: REDO 3D electroanatomic mapping ablation with gap targeting + linear lesion completion (mitral isthmus line, LA roof line). AC continuous through redo per RE-CIRCUIT (PMID 28530171). Mixed AF/AFL coexistence is the rule — ACC/AHA 2024 (PMID 38753446)
    inputs: hr, creatinine_egfr
    advance: Acute strategy + AC + EP redo-ablation referral booked
  9. 9DISPOSITION
    Admit if unstable, AAD initiation requiring monitoring (dofetilide REMS), recent ablation observation, or peri-ablation bridging; discharge if rate-controlled with AC and EP redo booked
    advance: Disposition documented
  10. 10MONITORING
    Telemetry; QTc on dofetilide / sotalol / amiodarone; post-redo-ablation observation for groin hematoma, tamponade, atrioesophageal fistula (LA mitral-isthmus line passes near esophagus — HIGHER RISK than CTI); AC adherence
    inputs: ecg_12_lead
    advance: Monitoring orders documented
  11. 11FOLLOWUP
    EP clinic at 4 weeks post-redo with 12-lead + Holter; AC continuation lifelong (mixed AF/AFL); lifestyle (alcohol, weight, OSA per LEGACY); 3, 6, 12-month Holter or wearable; counsel re: atrioesophageal fistula warning weeks 2-6 post-LA ablation
    advance: Follow-up booked + redo ablation pathway entered