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Atrial flutter: A newly recognized complication of pediatric lung transplantation Sanjiv K. Gandhi, MDa*, Burt I. Bromberg, MDb, George B. Mallory, MDc, Charles B. Huddleston, MDa The Journal of Thoracic and Cardiovascular Surgery Volume 112, Issue 4, Pages 984-991 (October 1996) DOI: 10.1016/S0022-5223(96)70099-5 Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 1 AFL with inverted p waves. A 12-lead electrocardiogram demonstrates the initiation of AFL in patient 1, marked by the arrow in the continuous lead II rhythm strip. Consecutive, nonconducted p waves are inverted in lead aVF, characteristic of spontaneous human type I AFL. The cycle length of the arrhythmia is 160 msec. AFL, Atrial flutter; AV, atrioventricular; f, flutter wave; SR, sinus rhythm. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 2 AFL with upright p waves. A 12-lead electrocardiogram demonstrates AFL with a cycle length of 160 msec and variable atrioventricular conduction in patient 2. Nonconducted p waves are upright in leads II, III, and aVF. f, Flutter wave. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 3 Variable electrocardiographic manifestations of AFL in the same patient. A, A 12-lead electrocardiogram in patient 4 demonstrates a rhythm with irregular R-R intervals, resembling atrial fibrillation. B, An esophageal electrocardiogram performed at the same time demonstrates a regularly irregular atrial rhythm. The atrial complexes occur at alternating cycle lengths of 260 and 510 msec. These depolarizations may represent sinus beats followed by atrial echo beats or they may be manifestations of a protected reentrant circuit with a cycle length of 260 msec, from which there is 3:2 exit block. C, A Holter recording in which slowed atrioventricular conduction unmasks the flutter waves. The cycle length of the tachycardia is 300 msec. D, A wide QRS complex tachycardia on the same Holter recording with an identical cycle length of 300 msec, probably representing AFL with aberrant ventricular conduction. A, Atrial depolarization; ESO, esophageal atrial lead; III, surface electrocardiogram lead III; ESO/III, hybrid lead of ESO and III; f, flutter wave; V, ventricular depolarization. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 3 Variable electrocardiographic manifestations of AFL in the same patient. A, A 12-lead electrocardiogram in patient 4 demonstrates a rhythm with irregular R-R intervals, resembling atrial fibrillation. B, An esophageal electrocardiogram performed at the same time demonstrates a regularly irregular atrial rhythm. The atrial complexes occur at alternating cycle lengths of 260 and 510 msec. These depolarizations may represent sinus beats followed by atrial echo beats or they may be manifestations of a protected reentrant circuit with a cycle length of 260 msec, from which there is 3:2 exit block. C, A Holter recording in which slowed atrioventricular conduction unmasks the flutter waves. The cycle length of the tachycardia is 300 msec. D, A wide QRS complex tachycardia on the same Holter recording with an identical cycle length of 300 msec, probably representing AFL with aberrant ventricular conduction. A, Atrial depolarization; ESO, esophageal atrial lead; III, surface electrocardiogram lead III; ESO/III, hybrid lead of ESO and III; f, flutter wave; V, ventricular depolarization. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 3 Variable electrocardiographic manifestations of AFL in the same patient. A, A 12-lead electrocardiogram in patient 4 demonstrates a rhythm with irregular R-R intervals, resembling atrial fibrillation. B, An esophageal electrocardiogram performed at the same time demonstrates a regularly irregular atrial rhythm. The atrial complexes occur at alternating cycle lengths of 260 and 510 msec. These depolarizations may represent sinus beats followed by atrial echo beats or they may be manifestations of a protected reentrant circuit with a cycle length of 260 msec, from which there is 3:2 exit block. C, A Holter recording in which slowed atrioventricular conduction unmasks the flutter waves. The cycle length of the tachycardia is 300 msec. D, A wide QRS complex tachycardia on the same Holter recording with an identical cycle length of 300 msec, probably representing AFL with aberrant ventricular conduction. A, Atrial depolarization; ESO, esophageal atrial lead; III, surface electrocardiogram lead III; ESO/III, hybrid lead of ESO and III; f, flutter wave; V, ventricular depolarization. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 3 Variable electrocardiographic manifestations of AFL in the same patient. A, A 12-lead electrocardiogram in patient 4 demonstrates a rhythm with irregular R-R intervals, resembling atrial fibrillation. B, An esophageal electrocardiogram performed at the same time demonstrates a regularly irregular atrial rhythm. The atrial complexes occur at alternating cycle lengths of 260 and 510 msec. These depolarizations may represent sinus beats followed by atrial echo beats or they may be manifestations of a protected reentrant circuit with a cycle length of 260 msec, from which there is 3:2 exit block. C, A Holter recording in which slowed atrioventricular conduction unmasks the flutter waves. The cycle length of the tachycardia is 300 msec. D, A wide QRS complex tachycardia on the same Holter recording with an identical cycle length of 300 msec, probably representing AFL with aberrant ventricular conduction. A, Atrial depolarization; ESO, esophageal atrial lead; III, surface electrocardiogram lead III; ESO/III, hybrid lead of ESO and III; f, flutter wave; V, ventricular depolarization. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 4 Esophageal pacing terminates AFL. Surface electrocardiogram leads II and aVL demonstrate a narrow complex tachycardia of fixed cycle length in patient 2. The diagnosis of AFL in this child was previously established (Fig. 2). The arrow marks the onset of the stimulus artifact from transesophageal pacing at a cycle length of 180 msec. After cessation of atrial burst pacing, the patient is in sinus rhythm. AFL, Atrial flutter; SR, sinus rhythm. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 984-991DOI: (10.1016/S0022-5223(96)70099-5) Copyright © 1996 Mosby, Inc. Terms and Conditions