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Atrial Electrical Activity: Absent or Scarcely Evident?

      To the Editor:
      We have read with great interest the article by Paulsen et al
      • Paulsen J.
      • Singh G.
      • Srivatsa U.
      • Amsterdam E.A.
      The case of the furtive flutter: atypical atrial flutter.
      that was recently published in The American Journal of Medicine. The authors describe how they managed to identify atrial electrical activity scarcely evident on the electrocardiogram (ECG) of a patient only after an ECG lead was attached directly to an atrial epicardial lead.
      In the 1970s, several authors reported cases in which atrial activity was not evident in baseline ECGs, only in endocavitary recordings.
      • DeMots H.
      • Brodeur M.T.
      • Rahimtoola S.H.
      Concealed sinus rhythmic: a cause of misdiagnosis of digitalis intoxication.
      • Friedman H.S.
      • Gomes J.A.
      • Tardio A.
      • et al.
      Appearance of atrial rhythm with absent P wave in longstanding atrial fibrillation.
      • Khan A.H.
      • Haider R.
      • Boughner D.R.
      • Oakley C.M.
      • Goodwin J.F.
      Sinus rhythm with absent P waves in advanced rheumatic heart disease.
      However, there are noninvasive recording methods that can help identify atrial activity. More than 30 years ago, we described how atrial activity could be identified using a wave amplification technique and 3 special superficial leads
      • Nordgren L.
      A new method to detect P waves in ECG signals.
      • Bayés de Luna A.
      • Boada F.X.
      • Casellas A.
      • et al.
      Concealed atrial electrical activity.
      in cases in which atrial activity is not evident in the baseline ECG (Figure 1A). In addition, by placing upper limb electrodes on the chest, as described by Sir Thomas Lewis,
      • Lewis T.
      Auricular fibrillation.
      along with voltage increase to 20 mm/mv, one can magnify the atrial activity in such cases. Nevertheless in the case described by Paulsen et al,
      • Paulsen J.
      • Singh G.
      • Srivatsa U.
      • Amsterdam E.A.
      The case of the furtive flutter: atypical atrial flutter.
      atrial activity was not clearly visible in most leads. F waves at an atrial rate of approximately 250 beats/min, especially in V1 to V3, can be seen with the help of a magnifying glass (Figure 1B).
      Figure thumbnail gr1
      Figure 1A, (1) ECG of a 66-year-old man with a heart rate of 55 beats/min. Atrial waves are not visible, simulating a junctional escape rhythm. (2) With the use of external and intracavitary ECG wave amplification, the concealed flutter waves were exposed. (3) After a successful cardioversion and because of external amplification of waves (SI A), a small but visible sinus P wave was identified (arrow). B, F waves at an atrial rate of approximately 250 beats/min can be seen in lead V1. ECG = electrocardiogram.
      We congratulate the authors for raising this interesting subject that is so rarely addressed in textbooks on electrocardiography.
      • Bayés de Luna A.
      Clinical Electrocardiology.

      References

        • Paulsen J.
        • Singh G.
        • Srivatsa U.
        • Amsterdam E.A.
        The case of the furtive flutter: atypical atrial flutter.
        Am J Med. 2014; 127: 1067-1069
        • DeMots H.
        • Brodeur M.T.
        • Rahimtoola S.H.
        Concealed sinus rhythmic: a cause of misdiagnosis of digitalis intoxication.
        Circulation. 1974; 50: 632-633
        • Friedman H.S.
        • Gomes J.A.
        • Tardio A.
        • et al.
        Appearance of atrial rhythm with absent P wave in longstanding atrial fibrillation.
        Chest. 1974; 66: 172-175
        • Khan A.H.
        • Haider R.
        • Boughner D.R.
        • Oakley C.M.
        • Goodwin J.F.
        Sinus rhythm with absent P waves in advanced rheumatic heart disease.
        Am J Cardiol. 1973; 32: 93-97
        • Nordgren L.
        A new method to detect P waves in ECG signals.
        Acta Soc Med Ups. 1969; 74: 264-268
        • Bayés de Luna A.
        • Boada F.X.
        • Casellas A.
        • et al.
        Concealed atrial electrical activity.
        J Electrocardiol. 1978; 11: 301-305
        • Lewis T.
        Auricular fibrillation.
        in: Clinical Electrocardiography. 5th ed. Shaw and Sons, London, UK1931: 87-100
        • Bayés de Luna A.
        Clinical Electrocardiology.
        Wiley-Blackwell, Oxford2010

      Linked Article

      • The Case of the Furtive Flutter: Atypical Atrial Flutter
        The American Journal of MedicineVol. 127Issue 11
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          A patient's arrhythmia was identified only after an electrocardiogram (ECG) lead was attached directly to an atrial epicardial lead. The 87-year-old man had a history of paroxysmal atrial fibrillation, coronary artery disease, and severe mitral and tricuspid regurgitation; he was admitted for corrective cardiac surgery. His history included a cardioembolic stroke 10 months prior to admission, hypertension, and hyperlipidemia. He underwent coronary artery bypass grafting (CABG) to the right coronary artery, bioprosthetic mitral valve replacement, tricuspid annulus repair, and a maze cryoablation or cryomaze procedure.
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