AFib vs Flutter Cycle Length-GOODpdf
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  1. 104Rev Esp Cardiol. 2007;60(2):104-9Differentiating Between Atrial Flutter and Atrial FibrillationUsing Right Atrial Bipolar Endocardial SignalsRodrigo Isa, Julián Villacastín, Javier Moreno, Nicasio Pérez-Castellano, Jorge Salinas, Manuel Doblado, Ricardo Morales, and Carlos MacayaUnidad de Arritmias, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, SpainORIGINAL ARTICLESCorrespondence: Dr. J. Villacastín.Unidad de Arritmias. Instituto Cardiovascular. Hospital Clínico San Carlos.Prof. Martín Lagos, s/n. 28040 Madrid. España.E-mail: jvillacastin@secardiologia.esReceived December 12, 2005.Accepted for publication November 2, 2006.INTRODUCTIONAtrial fibrillation and atrial flutter are 2 commonarrhythmias. Patients who primarily present atrialfibrillation generally also experience atrial flutter overthe course of their lives, and vice versa.1,2Since these arrhythmias differ in their underlyingphysiologic mechanisms and the currently availableIntroduction and objectives. Contemporary atrialpacemakers incorporate pacing modes for treating atrialarrhythmias. Because atrial fibrillation in the right atriumcan exhibit an organized pattern, it can be difficult todifferentiate from atrial flutter. We assessed criteria fordiscriminating between atrial flutter and organized atrialfibrillation when using a bipolar electrode in the right atrium.Methods. Simultaneous bipolar electrograms of theright and left atria were obtained in 45 patients: Group Icomprised 15 patients with atypical flutter, Group IIcomprised 15 with typical flutter, and Group III, 15 withorganized atrial fibrillation in the right atrium. The meancycle length and the mean variation in cycle lengthobserved over 15 seconds in electrograms of the rightatrium were recorded.Results. The mean cycle length was longer in Groups Iand II than in Group III (232 [21] ms and 234 [24] ms,respectively, vs 183 [16] ms; P<.001). The mean variationin cycle length was less in Groups I and II than in GroupIII (16 [7] ms and 13 [4] ms, respectively, vs 22 [7] ms;P<.01). A cycle length ≥203 ms discriminated atrial flutterfrom atrial fibrillation with a sensitivity of 97% and aspecificity of 87%. A cycle length variation ≤18 msdiscriminated atrial flutter from atrial fibrillation with asensitivity of 70% and a specificity of 80%.Conclusions. Cycle length was better than thevariation in cycle length for differentiating atrial flutter fromorganized atrial fibrillation.Key words: Atrial fibrillation. Atrial flutter. Arrhythmia.Diferenciación entre aleteo y fibrilaciónauricular en los electrogramas bipolares deaurícula derechaIntroducción y objetivos. Los modernos dispositivosauriculares incorporan estimulación para tratar arritmiasauriculares. La fibrilación auricular puede tener un patrónorganizado en la aurícula derecha, lo que dificulta el diag-nóstico diferencial con el aleteo auricular. Estudiamos loscriterios para discriminar un aleteo de una fibrilación auri-cular organizada utilizando un electrodo bipolar en la au-rícula derecha.Métodos. Se obtuvieron electrogramas bipolares simul-táneos de aurícula derecha e izquierda en 45 pacientes(grupo I: 15 pacientes con aleteo atípico; grupo II: 15 pa-cientes con aleteo típico, y grupo III: 15 pacientes con fi-brilación auricular organizada en la aurícula derecha). Semidieron la longitud de ciclo media y la variación mediade la longitud de ciclo en los electrogramas de aurículaderecha durante 15 s.Resultados. La longitud de ciclo fue mayor en los gru-pos I y II respecto al grupo III (232 ± 21 y 234 ± 24 frentea 183 ± 16 ms, respectivamente; p < 0,001). La variaciónmedia de la longitud de ciclo fue menor en los grupos I yII respecto al grupo III (16 ± 7 y 13 ± 4 frente a 22 ± 7 ms,respectivamente; p < 0,01). Una longitud de ciclo ≥203ms permitió discriminar un aleteo de una fibrilación auri-cular con una sensibilidad del 97% y una especificidaddel 87%. Una variación de la longitud de ciclo ≤18 mspermitió discriminar un aleteo auricular de una fibrilaciónauricular con una sensibilidad del 70% y una especifici-dad del 80%. Conclusiones. La longitud de ciclo fue mejor pará-metro diferenciador que la variación del ciclo para dis-tinguir un aleteo auricular de una fibrilación auricular or-ganizada. Palabras clave: Fibrilación auricular. Aleteo auricular.Arritmia.SEE EDITORIAL ON PAGES93-6Document downloaded from http://www.revespcardiol.org, day 20/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
  2. Isa R et al. Differentiating Between Atrial Flutter and Atrial Fibrillationtherapeutic options for their treatment, it is essential toclearly differentiate between them.3,4Differential diagnosis between atrial fibrillation andatrial flutter sometimes presents problems that are difficultto resolve, even with the use of endocardial electrograms.This is especially true when recordings are obtained witha single catheter electrode in the right atrium, as occurs,for example, with devices used for treatment ofsupraventricular tachyarrhythmia, since some episodesof atrial fibrillation can present with an organized electricalpattern in that chamber.The aim of this study was to identify anelectrophysiologic parameter that is easily identified witha single catheter electrode in the right atrium and thatallows discrimination between atrial flutter and organizedatrial fibrillation.METHODSIn patients requiring an electrophysiologic study forablation of atrial fibrillation, typical atrial flutter, oratypical atrial flutter (focal tachycardias were excluded),a 24-pole mapping catheter (Orbiter®, BardElectrophysiology) was introduced over the coronarysinus and the lateral tricuspid annulus. The catheter wasused to obtain simultaneous bipolar recordings from theright atrium (lateral tricuspid annulus and cavotricuspidisthmus) and the left atrium.Patients were selected from among individuals referredto our hospital for ablation of atrial fibrillation (n=32),typical atrial flutter (n=81), and atypical atrial flutter(n=15) who at the time of the electrophysiologic studypresented the arrhythmia to be treated or who developedthe arrhythmia spontaneously or with programmedstimulation during the procedure, and who met theinclusion criteria. The cases of atrial fibrillation had todisplay an organized electrical pattern (defined as afixed and reproducible sequence) in the right atrialrecordings over a period of at least 30 seconds and adisorganized pattern (fragmented signals, defined asatrial recordings with a duration of at least 150% of thebaseline atrial electrogram or lasting more than 100 ms)Figure 1. A and B: show surface andendocardial recordings in 2 patients withatrial fibrillation. In (A), irregular andfragmented signals are observed in thechannels corresponding to both atria, whilein (B), irregular, fragmented signals areseen in the channels corresponding to theleft atrium alongside organized signals inthe channels corresponding to the rightatrium. An organized pattern is seen inthe V1lead of the electrocardiogram(arrow). C) Left anterior oblique projectionshowing the position of the 24-polemapping catheter in the coronary sinusand right atrium. I, II, V1indicateelectrocardiography leads; A, atrialelectrogram; HRA, high right atrium; MRA,middle right atrium; LRA, low right atrium;PCS, proximal coronary sinus; MCS, middlecoronary sinus; DCS, distal coronary sinus.Rev Esp Cardiol. 2007;60(2):104-9105HRAHRAHRALRAPCSMCSDCSMRALRAPCSMCSDCSHRAHRALRAPCSMCSDCSDocument downloaded from http://www.revespcardiol.org, day 20/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
  3. in the coronary sinus (Figure 1). Typical atrial flutterwas defined as that which was dependent on thecavotricuspid isthmus, while atypical atrial flutter wasdefined as any macroreentrant arrhythmia presentingwith a completely organized electrical pattern in the 12electrodes of the recording and that was not dependentupon the cavotricuspid isthmus, using programmedstimulation.Cycle length was measured along with the variationin each atrial cycle in the electrograms obtained in thehigh right atrium, in the vicinity of the right atrialappendage (where the atrial wire electrode ofpacemakers for treatment of bradyarrhythmias ortachyarrhythmias is usually situated), in 3 consecutivebipolar channels over a period of 15 seconds.Recordings were obtained at a chart speed of 400 mm/sin an effort to ensure that they were as accurate aspossible.The patients included in the study had not had a previouselectrophysiologic study and were not receivingantiarrhythmia treatment at the time of the study.Statistical AnalysisData are expressed as means (SD). Quantitativevariables were compared by analysis of variance and theBonferroni correction was used to establish the differencesbetween the variables.Receiver operating characteristic curves were used todetermine the cut point for quantitative variables. Thearea below the curve was determined along with the 95%confidence interval (CI). The criterion validity of thetests was calculated for the maximum sensitivity andspecificity in the diagnosis of atrial flutter: sensitivity,specificity, positive and negative likelihood ratio, andpositive and negative predictive values. A P-value lessthan .05 was considered statistically significant. Statisticalanalysis was performed using SPSS (version 13.0) forWindows.RESULTSThe study included a total of 45 patients: 15 patientswith atypical atrial flutter, 15 with typical atrial flutter,and 15 with atrial fibrillation. The mean age of the patientswas 58 (11) years, 28 patients (62%) were men, 19 (42%)had arterial hypertension, 6 (13%) had diabetes mellitus,and 12 (27%) had structural heart disease (hypertensivein 7 patients [16%], ischemic in 4 [9%], and valvular in1 [2%]). The mean size of the left atrium was 43 (6) mm.No significant differences were observed in the baselinecharacteristics of the 3 groups, with the exception of age,which was significantly lower in the group of patientswith atrial fibrillation (Table).The patients with typical and atypical atrial flutteralready had the arrhythmia at the time of theelectrophysiologic study, and of the 15 patients with atrial106Rev Esp Cardiol. 2007;60(2):104-9 Isa R et al. Differentiating Between Atrial Flutter and Atrial Fibrillationfibrillation, 10 presented with the arrhythmia and 5developed sustained arrhythmia (more than 10 minutes)induced by programmed atrial stimulation.In the patients with atrial fibrillation, the activationfront in the right atrium was in a craniocaudaldirection in all cases, and an F wave was alwaysdiscernible in the V1lead of the surface electrocardiogramthat was stably associated with endocardial activation(Figure 1).Cycle LengthThe cycle length measured in the bipolar electrogramsof the right atrium was 232 (21) ms in the patients withatypical atrial flutter (range, 224 [22] to 240 [21] ms),234 (24) ms in the group with typical atrial flutter (range,227 [24] to 240 [25] ms), and 183 (16) ms in the groupwith atrial fibrillation (range, 172 [15] to 194 [17] ms)(P=NS between the groups with typical and atypicalatrial flutter and P<.05 between the 2 groups with atrialflutter and the group with atrial fibrillation). A cyclelength ≥203 ms allowed discrimination between atrialflutter and atrial fibrillation with a sensitivity of 97%(95% CI, 90.2%-100%) and a specificity of 87% (95%CI, 69.5%-100%) (P<.001) (Figures 2A and 3A). Thepositive likelihood ratio for this value was 7.25 (95%CI, 1.99-26.39) and the negative likelihood ratio, 0.04(95% CI, 0.01-0.27). The positive predictive value withthis cut point was 94% (95% CI, 84.9%-100%) and thenegative predictive value, 93% (95% CI, 79.4%-100%).Cycle Length VariationThe cycle length variation was 16 (7) ms in theatypical atrial flutter group, 13 (4) ms in the typicalTABLE 1. Patient Characteristics*Atypical Typical Atrial PAtrial Atrial FibrillationFlutter Flutter (n=15)(n=15) (n=15)Age, y 60 (8) 65 (9) 50 (12) .01†Men, n (%) 8 (53) 10 (67) 10 (67) NSArterial hypertension, 7 (47) 6 (40) 6 (40) NSn (%)Diabetes mellitus, n (%) 3 (20) 2 (13) 1 (7) NSStructural heart disease, 5 (33) 4 (27) 3 (20) NSn (%)Hypertensive, n (%) 3 (20) 2 (13) 2 (13) NSIschemic, n (%) 2 (13) 1 (7) 1 (7) NSValvular, n(%) – 1 (7) –Left atrial size 43 (5) 41 (5) 45 (6) NS*Data are shown as mean (SD) except where otherwise indicated. NS indica-tes not significant.†Difference between patients with atrial fibrillation and those with atypicalatrial flutter.Document downloaded from http://www.revespcardiol.org, day 20/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
  4. atrial flutter group, and 22 (7) ms in the atrial fibrillationgroup (P<.05 between typical atrial flutter and atrialfibrillation; P=NS between the other groups) (Figure2B). A cycle length variation ≤18 ms alloweddiscrimination between atrial flutter and atrialfibrillation with a sensitivity of 70% (95% CI, 53.6%-86.4%) and a specificity of 80% (95% CI, 59.8%-100%)(Figure 3B). The positive likelihood ratio for this valuewas 3.5 (95% CI, 1.24-9.89) and the negative likelihoodratio, 0.38 (95% CI, 0.21-0.67). The positive predictivevalue with this cut point was 88% (95% CI, 74.3%-100%) and the negative predictive value, 57% (95%CI, 36%-78.3%).Cycle Length and VariationUsing a combination of both criteria to discriminatebetween atrial flutter and atrial fibrillation (cycle length≥203 ms and cycle length variation ≤18 ms) yielded asensitivity of 99%, a specificity of 69%, a positivepredictive value of 26%, and a negative predictive valueof 99%.DISCUSSIONPrincipal FindingsTwo main observations were made in our study. Firstly,that there are significant differences in right atrial cyclelength and cycle length variation between atrial flutterand atrial fibrillation that presents with an organizedpattern. Cycle length was greater and cycle length variationlower in atrial flutter than in atrial fibrillation, with nosignificant differences between the 2 types of atrial flutter.Secondly, cycle length was a better parameter than cyclelength variation to differentiate between atrial flutter andNSNSP<.0535302520151050AtypicalFlutterBCycle Length Variation, ms203 msAtypicalFlutterA300280260240220200180160140120100Cycle Length, msTypicalFlutterTypicalFlutterAtrialFibrillationAtrialFibrillationA1.00.80.60.40.20.0Sensitivity0.0 0.2 0.4 0.6 0.8 1.01–SpecificityAUC, 0.98795% CI, 0.963-1.011B1.00.80.60.40.20.0Sensitivity0.0 0.2 0.4 0.6 0.8 1.01–SpecificityAUC, 0.77795% CI, 0.628-0.925Figure 2. A) Cut point for discriminationbetween both groups of patients with atrialflutter and patients with atrial fibrillationin terms of cycle length. B) Cycle lengthvariation in the 3 groups.CL indicates cycle length.Figure 3. Receiver operating characteristiccurves for cycle length (A) and cycle lengthvariation (B).AUC indicates area under the curve; CI,confidence interval.Isa R et al. Differentiating Between Atrial Flutter and Atrial FibrillationRev Esp Cardiol. 2007;60(2):104-9107Document downloaded from http://www.revespcardiol.org, day 20/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
  5. this subset of atrial fibrillation. A cycle length ≥203 msallowed discrimination between atrial flutter and atrialfibrillation with a good sensitivity and specificity; atrialflutter was found to be 7.25 times more likely when thecycle length is above this cut point and it is 25 timesmore likely that this diagnosis is ruled out when a valuefor cycle length below the cut point is obtained. A slightincrease in the sensitivity of the test was observed whenthe 2 parameters were combined, but this was associatedwith a significant reduction in specificity. Consequently,the use of a combination of the 2 variables did not improvethe diagnostic yield.Minimum cycle length was not considered in theanalysis, since this parameter could contain artifacts thatwould generate excessively short intervals and lead tooverestimation of the diagnosis of atrial fibrillation.Organized Atrial Fibrillation in theRight AtriumCurrently, there is no simple definition of atrialfibrillation that is applicable to both electrocardiogramsand electrophysiologic recordings. It has been reportedthat atrial fibrillation and atrial flutter represent 2arrhythmias that are interrelated and that, via differentmechanisms, each participates in the genesis of the other.5However, both arrhythmias can coexist in the samepatients, making differential diagnosis difficult, especiallywhen it involves atypical atrial flutter or organized atrialfibrillation. This type of atrial fibrillation is characterizedby a disorganized pattern of endocardial activation inthe left atrium and an organized pattern in the rightatrium, as has been described by some authors6-9and aswe have illustrated in this study. In a case series involving16 patients with atrial fibrillation in whom endocardialmapping was performed at different sites in the rightatrium and coronary sinus over a period of 50 minutes,Roithinger et al9observed that in up to 72% of the timeperiod there was organized activation in the trabecularregion of the right atrium, compared with only 19% ofthe time in the smooth wall of that chamber and 51% ofthe time in the coronary sinus. However, this has notbeen studied systematically in the population of patientswith atrial fibrillation, and consequently, its prevalence,clinical significance, and therapeutic implications areunknown, and no clear explanation of the underlyingmechanism is available. One possible hypothesis toexplain this pattern of electrical activation in somepatients is that the primary circuit responsible forsustaining atrial fibrillation is located in the left atrium,while the right atrium is passively activated. In thiscontext, interatrial conduction has been studied and ithas been demonstrated that both atria communicate witheach other via preferential routes of conduction locatedaround the ostium of the coronary sinus, the fossa ovalis,and the anterosuperior region of the interatrial septum.10It is likely that, similar to events associated with the108Rev Esp Cardiol. 2007;60(2):104-9 Isa R et al. Differentiating Between Atrial Flutter and Atrial Fibrillationgenesis of atrial flutter, this pattern of electrical activationin the right atrium observed during atrial fibrillationoccurs as a result of a functional block via the cristaterminalis. Thus, fibrillatory conduction arising fromthe left atrium, modulated in some way throughBachmann’s bundle and the other preferential fibers,would be organized and display an organized activationpattern in a craniocaudal direction in the lateral wall andin a caudocranial direction in the septal wall of the rightatrium, or vice versa, imitating the activation pattern ofatrial flutter dependent upon the isthmus.11Thismodulation of conduction between the left and rightatria has been studied to some extent by O’Donnell etal.12Those authors analyzed the refractory periods andconduction times of Bachmann’s bundle and the ostiumof the coronary sinus in patients referred for ablation ofatrial fibrillation. They observed that both the refractoryperiods and the delayed conduction through thosestructures during decremental pacing from the left atriumwere significantly greater in patients with atrial fibrillationthan in a control group, indicating that those structuresdisplay an electrophysiologic behavior that varies ineach patient.12Clinical UsefulnessRapid detection of atrial tachyarrhythmias and reliablediscrimination between atrial flutter and atrial fibrillationhave important clinical implications for the use andprogramming of pacemakers and defibrillators that candeliver atrial therapies. In these patients, atrialantitachycardia pacing is reported to be effective in 30%to 50% of the episodes, depending on the study.13-15Itis known that atrial arrhythmias (atrial tachycardia,atrial flutter, and atrial fibrillation) are interrelated, andin this sense, the low relative efficacy of pacing therapymay be due to an incorrect interpretation of thearrhythmia detected by the device, even more so if atrialdetection is performed by a single catheter electrodeimplanted in the right atrium. This could be the causeof detection errors and ineffective therapy. However,from a clinical perspective, it is advisable that the devicebe programmed in such a way that significantunderdetection of episodes of atrial flutter does notoccur, even though some episodes of atrial fibrillationare treated by antitachycardia pacing. This easily appliedalgorithm is also of practical use duringelectrophysiologic studies of patients with tachycardiasin those cases in which only a single catheter electrodeis available in the right atrium, in order to be able torapidly discriminate between atrial flutter and organizedatrial fibrillation.Previous StudiesVarious methods have been used in an effort todifferentiate between atrial flutter and atrial fibrillation.Document downloaded from http://www.revespcardiol.org, day 20/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
  6. Some of those methods are easy to apply. Jung et al16studied 28 patients and found that a mean cycle lengthof more than 315 ms discriminated those patients withnormal sinus rhythm from those with atrial flutter oratrial fibrillation, and that an SD of more than 11.5 msdiscriminated those with atrial fibrillation from thosewith atrial flutter. However, that study did not specifywhether or not the episodes of atrial fibrillation presentedan organized activation pattern in recordings from theright atrium. Other authors have employed complexmethods that require the use of specific analyzers todiscriminate between atrial flutter and atrial fibrillation,such as evaluation of the intersignal variability using atransform and calculation of the SD for different scales,17Bayesian analyses with a series of elements such asregularity, rate, energy distribution of the obtained signals,etc,18and time-domain analysis of the QRS complex-subtracted electrocardiogram.19In general, all of theseproposed algorithms display an adequate diagnostic yieldto obtain a differential diagnosis between the 2arrhythmias. However, their use is essentially limited toresearch applications because of the time required fortheir analysis and the need for specific technology.LimitationsThe main limitation of our study is that the patientswith atrial fibrillation belong to a selected population ofpatients referred for ablation of atrial fibrillation. As such,the results might not be applicable to the generalpopulation of patients with atrial fibrillation.CONCLUSIONSCycle length and cycle length variation in electrogramsrecorded from the right atrium are significantly differentbetween atrial flutter and organized atrial fibrillation inthe right atrium, with a longer cycle length and lowercycle length variation in atrial flutter. A cycle length ≥203ms allowed discrimination between atrial flutter and atrialfibrillation with good sensitivity and specificity. Cyclelength variation did not improve the diagnostic yield indistinguishing between the 2 arrhythmias.REFERENCES1. Waldo AL. Atrial flutter. In: Podrid PJ, Kowey PR, editors. Cardiacarrhythmia: mechanisms, diagnosis and management. 2nd ed.Baltimore: Williams & Wilkins; 2001. p. 501-16.2. Biblo LA, Yuan Z, Quan KJ, Mackall JA, Rimm AA. Risk of strokein patients with atrial flutter. Am J Cardiol. 2001;87:17-20.3. Verma A, Natale A. Should atrial fibrillation ablation be consideredfirst-line therapy for some patients? Why atrial fibrillation ablationshould be considered first-line therapy for some patients. Circulation.2005;112:1214-22.4. Morady F. Catheter ablation of supraventricular arrhythmias: stateof the art. J Cardiovasc Electrophysiol. 2004;15:124-39.5. Wells JL, MacLean WA, James TN, Waldo AL. Characterizationof atrial flutter. Studies in man after open heart surgery using fixedatrial electrodes. Circulation. 1979;60:665-73.6. Wells JL, Karp RB, Kouchoukos NT, MacLean WA, James TN,Waldo AL. Characterization of atrial fibrillation in man: studiesfollowing open heart surgery. Pacing Clin Electrophysiol. 1978;1:426-38.7. Waldo A. Inter-relationships between atrial flutter and atrialfibrillation. Pacing Clin Electrophysiol. 2003;26:1583-96.8. Jais P, Haissaguerre M, Shah DC, Chouairi S, Clementy J.Regional disparities of endocardial atrial activation in paroxysmalatrial fibrillation. Pacing Clin Electrophysiol. 1996;19:1998-2003.9. Roithinger FX, SippensGroenewegen A, Karch MR, Steiner PR,Ellis WS, Lesh MD. Organized activation during atrial fibrillationin man: endocardial and electrocardiographic manifestations. JCardiovasc Electrophysiol. 1998;9:451-61.10. Roithinger FX, Cheng J, SippensGroenewegen A, Lee RJ, SaxonLA, Scheinman MM, et al. Use of electroanatomic mapping todelineate transseptal atrial conduction in humans. Circulation.1999;100:1791-7.11. Arenal A, Almendral J, Alday JM, Villacastin J, Ormaetxe JM,Sande JL, et al. Rate-dependent conduction block of the cristaterminalis in patients with typical atrial flutter: influence on evaluationof cavotricuspid isthmus conduction block. Circulation. 1999;99:2771-8.12. O’Donnell D, Bourke JP, Furniss SS. Interatrial transseptal electricalconduction: comparison of patients with atrial fibrillation and normalcontrols. J Cardiovasc Electrophysiol. 2002;13: 11117.13. Ricci R, Santini M, Padeletti L, Boriani G, Capucci A, Botto G, etal. Atrial tachyarrhytmia recurrence temporal patterns in bradycardiapatients implanted with antitachycardia pacemakers. J CardiovascElectrophysiol. 2004;15:44-51.14. Boriani G, Padeletti L, Santini M, Gulizia M, Capucci A, BottoG. Predictors of atrial antitachycardia pacing efficacy inpatientsaffected by brady-tachy form of sick sinus syndrome andimplanted with a DDDRP device. J Cardiovasc Electrophysiol.2005;16:714-23.15. Gillis AM, Koehler J, Morck M, Mehra R, Hettrick DA. High atrialantitachycardia pacing therapy efficacy is associated with a reductionin atrial tachyarrhythmia burden in a subset of patients with sinusnode dysfunction and paroxysmal atrial fibrillation. Heart Rhytm.2005;2:791-6.16. Jung J, Hohenberg G, Heisel A, Strauss D, Schieffer H, Fries R.Discrimination of sinus rhytm, atrial flutter, and atrial fibrillationusing bipolar endocardial signals. J Cardiovasc Electrophysiol.1998;9:689-95.17. Jung J, Strauss D, Sinnwell T, Hohenberg G, Fries R, Wern H, etal. Assesment of intersignal variability for discrimination of atrialfibrillation from atrial flutter. Pacing Clin Electrophysiol. 1998;21:2426-30.18. Xu W, Tse HF, Chan FH, Fung PC, Lee KL, Lau CP. New bayesiandiscriminator for detection of atrial tachyarrhythmias. Circulation.2002;105:1472-9.19. Taha B, Reddy S, Xue Q, Swiryn S. Automated discriminationbetween atrial fibrillation and atrial flutter in the resting 12-leadelectrocardiogram. J Electrocardiol. 2000;33 Suppl:123-5.Isa R et al. Differentiating Between Atrial Flutter and Atrial FibrillationRev Esp Cardiol. 2007;60(2):104-9109Document downloaded from http://www.revespcardiol.org, day 20/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
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