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Pediatric Atrial Flutter Clinical Presentation

  • Author: M Silvana Horenstein, MD; Chief Editor: Steven R Neish, MD, SM  more...
Updated: Feb 11, 2014


The setting and associated features of atrial flutter are an important aspect of the assessment of atrial flutter. This information may guide the design of a treatment plan, particularly in patients with repaired congenital heart disease.

Atrial flutter may be perceived as a regular or irregular palpitation, the latter suggesting variable atrioventricular (AV) conduction. The flutter may be associated with syncope, severe presyncope, or chest pain, suggesting either periods of 1:1 conduction ratio or associated ventricular dysfunction. Characterizing a history of previous self-terminating episodes is important. Rare and minimally symptomatic self-terminating episodes of atrial flutter are likely to require less treatment.

The presence of associated sinus node disease with episodes of sinus bradycardia may provide an indication for pacemaker therapy. This finding also adds to the antiarrhythmic medical options for atrial flutter.

Repaired congenital heart disease

Understanding the specific anatomy and surgical repair for each patient is important. Certain types of repair are more commonly associated with late atrial flutter than others.

In Fontan-type operations, atriopulmonary connections are associated with a risk of atrial flutter that is 2.5-fold higher than with the total cavopulmonary connection. Extracardiac Fontan repairs may have an even lower frequency of atrial flutter.

The type of repair may influence the technical approach to electrophysiological study, pacemaker placement, potential radiofrequency ablation therapy, or potential Fontan surgical revision. For example, patients who have the classic Fontan operation are amenable to ablation attempts of the atrial flutter in the electrophysiology laboratory because the right atrium can be approached via the inferior and/or superior vena cava. In addition, endocardial pacemaker leads can be inserted if the patient has sinus node dysfunction.

However, patients who have an extracardiac Fontan repair in which the right atrium has been bypassed with a baffle require open-heart surgery if ablation is contemplated, which is performed at the time of their Fontan revision. In addition, only epicardial pacemaker leads can be placed in these patients.

Atrial flutter also has prognostic significance in this setting. Several studies have shown that atrial flutter in the early postoperative period in patients who have undergone the Fontan operation predicts both early operative mortality and recurrence of the arrhythmia.

In patients with congenital heart disease who have undergone surgery, episodes of atrial flutter have been shown to increase in frequency over time.


Physical Examination

Physical examination in patients with atrial flutter should assess the likely conduction ratio and rate of flutter and assess for signs of associated ventricular dysfunction or heart failure. Depending on the ventricular rate and the individual's tolerance to that rate, symptoms may range from palpitations, dyspnea, presyncope, or syncope to sudden death. If the ventricular response is rapid, atrial flutter may cause significant morbidity secondary to hemodynamic deterioration due to low cardiac output.

If the ventricular response is slow enough to permit a sustained arrhythmia, atrial thrombosis with consequent thromboembolism may result. In patients who have undergone surgery for congenital heart disease, new onset of atrial arrhythmias such as atrial flutter may indicate elevated right atrial pressure and, thus, the need for surgery (eg, conduit obstruction in a patient with a Rastelli-type surgery).

In patients who have undergone the Fontan, Mustard, or Senning operation, the presence of superficial venous collateralization suggests associated obstruction of major venous pathways. This may interfere with evaluation and management.


Episodes of atrial flutter may be associated with low cardiac output, brain and other end-organ injury, and sudden or subacute death.

Heart failure, thrombosis, and thromboembolism are other recognized complications.

Contributor Information and Disclosures

M Silvana Horenstein, MD Assistant Professor, Department of Pediatrics, University of Texas Medical School at Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc

M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Medical Association

Disclosure: Nothing to disclose.


Robert Murray Hamilton, MD, MSc, FRCPC Electrophysiologist, Senior Associate Scientist, Physiology and Experimental Medicine, Labatt Family Heart Centre; Professor, Department of Pediatrics, University of Toronto Faculty of Medicine

Robert Murray Hamilton, MD, MSc, FRCPC is a member of the following medical societies: American Heart Association, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Heart Rhythm Society, Canadian Cardiovascular Society, Cardiac Electrophysiology Society, Pediatric and Congenital Electrophysiology Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine

Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.


Alvin J Chin, MD Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Cardiology Division, Children's Hospital of Philadelphia

Alvin J Chin, MD, is a member of the following medical societies: American Association for the Advancement of Science, American Heart Association, and Society for Developmental Biology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

  1. Biviano A, Garan H, Hickey K, Whang W, Dizon J, Rosenbaum M. Atrial flutter catheter ablation in adult patients with repaired tetralogy of Fallot: mechanisms and outcomes of percutaneous catheter ablation in a consecutive series. J Interv Card Electrophysiol. 2010 Aug. 28(2):125-35. [Medline].

  2. Boriani G, Gallina M, Merlini L, et al. Clinical relevance of atrial fibrillation/flutter, stroke, pacemaker implant, and heart failure in Emery-Dreifuss muscular dystrophy: a long-term longitudinal study. Stroke. 2003 Apr. 34(4):901-8. [Medline].

  3. Nazarian S, Wagner KR, Caffo BS, Tomaselli GF. Clinical predictors of conduction disease progression in type I myotonic muscular dystrophy. Pacing Clin Electrophysiol. 2011 Feb. 34(2):171-6. [Medline]. [Full Text].

  4. Frost L, Hune LJ, Vestergaard P. Overweight, obesity and risk factors for atrial fibrillation or flutter--secondary publication.The cohort study Diet, Cancer and Health. Ugeskr Laeger. 2005 Sep 12. 167(37):3507-9. [Medline].

  5. Frost L, Vestergaard P. Alcohol consumption and the risk of atrial fibrillation or flutter--secondary publication. A cohort study. Ugeskr Laeger. 2005 Aug 29. 167(35):3308-10. [Medline].

  6. Frost L, Vestergaard P, Mosekilde L. Hyperthyroidism and risk of atrial fibrillation or flutter--secondary publication. A population-based study. Ugeskr Laeger. 2005 Aug 29. 167(35):3305-7. [Medline].

  7. Movahed MR, Hashemzadeh M, Jamal MM. Diabetes mellitus is a strong, independent risk for atrial fibrillation and flutter in addition to other cardiovascular disease. Int J Cardiol. 2005 Dec 7. 105(3):315-8. [Medline].

  8. Earing MG, Cetta F, Driscoll DJ. Long-term results of the Fontan operation for double-inlet left ventricle. Am J Cardiol. 2005 Jul 15. 96(2):291-8. [Medline].

  9. Balaji S, Daga A, Bradley DJ, Etheridge SP, Law IH, Batra AS, et al. An international multicenter study comparing arrhythmia prevalence between the intracardiac lateral tunnel and the extracardiac conduit type of Fontan operations. J Thorac Cardiovasc Surg. 2013 Oct 27. [Medline].

  10. Krapp M, Kohl T, Simpson JM. Review of diagnosis, treatment, and outcome of fetal atrial flutter compared with supraventricular tachycardia. Heart. 2003 Aug. 89(8):913-7. [Medline].

  11. Southall DP, Johnson AM, Shinebourne EA, Johnston PG, Vulliamy DG. Frequency and outcome of disorders of cardiac rhythm and conduction in a population of newborn infants. Pediatrics. 1981 Jul. 68(1):58-66. [Medline].

  12. Silversides CK, Harris L, Haberer K. Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. Am J Cardiol. 2006 Apr 15. 97(8):1206-12. [Medline].

  13. Liberman L, Pass RH, Starc TJ. Optimal surface electrocardiogram lead for identification of the mechanism of supraventricular tachycardia in children. Pediatr Emerg Care. 2008 Jan. 24(1):28-30. [Medline].

  14. Liberman L, Hordof AJ, Altmann K, Pass RH. Low energy biphasic waveform cardioversion of atrial arrhythmias in pediatric patients and young adults. Pacing Clin Electrophysiol. 2006 Dec. 29(12):1383-6. [Medline].

  15. Stulak JM, Dearani JA, Puga FJ. Right-sided Maze procedure for atrial tachyarrhythmias in congenital heart disease. Ann Thorac Surg. 2006 May. 81(5):1780-4; discussion 1784-5. [Medline].

  16. Naccarelli GV, Wolbrette DL, Levin V, et al. Safety and efficacy of dronedarone in the treatment of atrial fibrillation/flutter. Clin Med Insights Cardiol. 2011. 5:103-19. [Medline]. [Full Text].

  17. Oudijk MA, Ruskamp JM, Ververs FF, et al. Treatment of fetal tachycardia with sotalol: transplacental pharmacokinetics and pharmacodynamics. J Am Coll Cardiol. 2003 Aug 20. 42(4):765-70. [Medline].

  18. Rebelo M, Macedo AJ, Nogueira G, Trigo C, Kaku S. Sotalol in the treatment of fetal tachyarrhythmia. Rev Port Cardiol. 2006 May. 25(5):477-81. [Medline].

Rhythm strip depicting lead II of a patient with atrial flutter with an atrial rate of 300 beats per minute (bpm). Atrioventricular conduction rate is variable at 2:1 and 3:1. Therefore, the ventricular rate ranges from 100-150 bpm.
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