From the Guidelines
The development of atrial flutter with tricuspid heart block in an 82-year-old man three months after triple bypass with maze surgery is likely related to post-surgical scarring and inflammation, and this patient should be evaluated promptly by a cardiologist for potential management with rate-controlling medications, anticoagulation therapy, and possible cardioversion or catheter ablation. The maze procedure, which creates controlled scar tissue to block abnormal electrical pathways, can sometimes lead to unintended conduction disturbances as the heart heals, as described in the acc/aha 2008 guidelines for the management of adults with congenital heart disease 1. Inflammation around the tricuspid valve area may have affected the atrioventricular node, causing the heart block. Other potential causes include electrolyte imbalances (particularly potassium or magnesium), medication side effects (such as beta-blockers, calcium channel blockers, or antiarrhythmics), or progression of underlying cardiac disease. Key considerations for management include:
- Rate-controlling medications (such as diltiazem 120-360 mg daily or metoprolol 25-200 mg daily) to control the ventricular response, as recommended in the 2009 accf/aha focused update on perioperative beta blockade 1
- Anticoagulation therapy (such as apixaban 5 mg twice daily) to prevent thromboembolic complications
- Possible cardioversion or catheter ablation if the arrhythmia persists, with the goal of restoring normal sinus rhythm and improving quality of life Electrophysiology studies may be needed to determine if a pacemaker is required for the heart block, as bradyarrhythmias due to sinus node dysfunction and advanced conduction abnormalities such as complete heart block will respond to temporary or permanent transvenous pacing or permanent pacing 1. Close monitoring of heart rhythm and symptoms is essential as the patient continues recovery from cardiac surgery, with attention to potential complications such as atrial fibrillation and atrial flutter, which are common in patients with a history of cardiac surgery, as noted in the acc/aha/esc guidelines for the management of patients with supraventricular arrhythmias 1.
From the Research
Possible Causes of Atrial Flutter with Trifascicular Block
The development of atrial flutter with a trifascicular block in an 82-year-old man who had triple bypass with maze surgery 3 months ago can be attributed to several factors, including:
- Atrial remodeling and scarring from the maze surgery, which can create a substrate for reentrant arrhythmias such as atrial flutter 2, 3
- Iatrogenic atrial scars from the surgical procedure, which can disrupt normal atrial conduction and lead to the development of atrial flutter 2, 4
- Underlying cardiac disease, such as coronary artery disease, which can contribute to the development of atrial flutter 5, 6
- Age-related changes in the cardiac conduction system, which can increase the risk of developing atrial flutter and trifascicular block 5, 6
Mechanisms of Atrial Flutter
Atrial flutter is a macroreentrant arrhythmia that can occur in the right or left atrium, and is often associated with a recognizable ECG pattern 2, 5. The mechanism of atrial flutter involves reentry in a macroreentrant circuit, which can be facilitated by atrial scarring and remodeling 2, 3.
Treatment Options
Treatment options for atrial flutter with trifascicular block include:
- Catheter ablation, which can be effective in eliminating the arrhythmia and improving symptoms 2, 5
- Medical management with antiarrhythmic drugs and rate-controlling medications, although this may be less effective in patients with underlying cardiac disease and atrial scarring 5, 6
- Electrical cardioversion, which can be used to terminate the arrhythmia in unstable patients 6