Analysis of variable conduction ratios into the atrioventricular node during atrial flutter: Multilevel block theory Kazushi Tanaka, MD, PhD, FACC, Osamu.

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Analysis of variable conduction ratios into the atrioventricular node during atrial flutter: Multilevel block theory Kazushi Tanaka, MD, PhD, FACC, Osamu Fujimura, MD, FACC HeartRhythm Case Reports Volume 5, Issue 5, Pages 274-276 (May 2019) DOI: 10.1016/j.hrcr.2019.02.004 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1 Surface 12-lead electrocardiogram with rhythm strips (V1 and II) showing a variety of atrioventricular conduction ratios during atrial flutter. The cycle length (CL) of atrial flutter (FCL), 20 flutter CLs in lead V1, and R-R intervals in II are displayed. Total intervals of 20 FCLs are 4800 and 4900 ms, which make the FCLs 240 and 245 ms in panels A and B, respectively. A: Group beating with short-long (560-860 ms) sequence. B: Short-short-long (560-540-860 ms) group beating. HeartRhythm Case Reports 2019 5, 274-276DOI: (10.1016/j.hrcr.2019.02.004) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2 Analysis of a variety of atrioventricular (AV) conductions during atrial flutter (AFL) using ladder diagrams with measurement of the driving cycle length (CL) during Wenckebach periodicity. Numbers on arrows and downward arrowheads in lead V1 indicate AV conduction times and impulses of AFL, respectively. Numbers in Atrium indicate AFL waves, of which the number 1 indicates the first AFL impulse conducting to the ventricle after the long pause. A and B = the upper and lower level into the AV node (AVN), respectively. Single and double splashes indicate conduction block at A and B into the AVN, respectively. A: Typical 3:1 Wenckebach type 1 AV block within the level of B is shown, where the degree of conduction is variable but the conduction time via the decremental tissue after Wenckebach type 1 AV block is assumed to return to the baseline with the constant value (T ms). In this diagram, the interval (Y) between first R waves following a long pause (880 ms) is equal to 3 times the driving CL (X), 1440 ms. Therefore, the driving CL then is calculated as X = Y/3, namely 480 ms. B: Also, 4:1 Wenckebach AV block is illustrated. The X is equal to Y (1960 ms = 560 + 540 + 860 ms)/4, namely 490 ms. See text for details. FCL = CL of atrial flutter; HPS = His-Purkinje system. HeartRhythm Case Reports 2019 5, 274-276DOI: (10.1016/j.hrcr.2019.02.004) Copyright © 2019 Heart Rhythm Society Terms and Conditions