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Journal List > Heart > v.80(1); Jul 1998
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PubMed articles by:
Lai, L.
Lin, J.
Lin, L.
Huang, S.
Heart. 1998 July; 80(1): 80–85.
PMCID: PMC1728760
Copyright notice
New electrocardiographic criteria for the differentiation between counterclockwise and clockwise atrial flutter: correlation with electrophysiological study and radiofrequency catheter ablation
L Lai, J Lin, L Lin, W Chen, Y Ho, Y Tseng, C Chen, Y Lee, W Lien, and S Huang
Department of Internal Medicine, National Taiwan University Hospital, Taipei.
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Abstract
Objective—To develop new electrocardiographic (ECG) criteria for the differentiation between counterclockwise and clockwise atrial flutters.
Background—Traditionally, the ECG differentiation between counterclockwise and clockwise atrial flutters is based on the flutter wave polarity in the inferior leads. However, determination of flutter wave polarity is subjective and sometimes difficult, especially in flutter waves of undulating pattern.
Patients—The study comprised 37 consecutive patients with drug resistant atrial flutter; 30 had counterclockwise and 17 had clockwise atrial flutter (10 had both forms of atrial flutter). The isthmus dependence was confirmed by entrainment study and catheter ablation. The ECG patterns of both types of atrial flutter were compared and the flutter wave polarity in the inferior leads was determined by four independent cardiologists.
Results—The flutter wave polarity in the inferior leads appeared negative in 24, positive in one, and equivocal in five of the counterclockwise atrial flutters; polarity appeared negative in one, positive in 10, and equivocal in six of the clockwise atrial flutters. However, the aVF/lead I flutter wave amplitude ratio was > 2.5 in all counterclockwise but < 2.5 in all clockwise atrial flutters. The flutter wave nadirs in the inferior leads corresponded to the upstrokes in V1 in all counterclockwise atrial flutters, but corresponded to the downstrokes in V1 in all clockwise atrial flutters.
Conclusions—The flutter wave polarity in the inferior leads does not correlate well with the flutter wave rotating direction. However, counterclockwise and clockwise atrial flutters can be differentiated by new ECG criteria with high accuracy.

Keywords: atrial flutter;  radiofrequency catheter ablation;  electrocardiography
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Selected References
These references are in PubMed. This may not be the complete list of references from this article.
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Figures and Tables
Figure 1 Figure 1  
Fluoroscopic picture and electrograms during mapping and entrainment study. (A) Position of the Halo catheter in the right atrium (60° left anterior oblique projection). (B) Entrainment study in a patient with counterclockwise atrial flutter. (more ...)
Figure 2 Figure 2  
Twelve lead ECG (left panel; 25 mm/second) and intracardiac electrograms (right panel; 50 mm/second) from (A) patient 19 and (B) patient 5 in table 1. Both had counterclockwise atrial flutter as shown by the Halo catheter (more ...)
Figure 3 Figure 3  
Twelve lead ECG (left panel; 25 mm/second) and intracardiac electrograms (right panel; 50 mm/second) from (A) patient 17 and (B) patient 24 in table 1. Both had clockwise atrial flutter as shown by the Halo catheter study, (more ...)
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