Ventricular Flutter

Clinical Significance

• Extreme form of VT with loss of organised electrical activity
• Associated with rapid and profound hemodynamic compromise
• Usually short lived due to progression to ventricular fibrillation
• As with ventricular fibrillation rapid initiation of advanced life support is required

 How to Recognise Ventricular Flutter

• Continuous Sine Wave
• No identifiable P waves, QRS complexes, or T waves
• Rate usually > 200 beats / min

 Pearls

• The ECG looks identical when viewed upside down!

ECG Examples

Example 1

Typical appearance of ventricular flutter:

• Monomorphic sine wave at >200bpm.
• ECG looks identical when turned upside down.

Example 2

12-lead ECG example of ventricular flutter:

• Extremely rapid monomorphic sine wave at around 300 bpm.

Example 3 – Ventricular flutter following a bolus of intravenous verapamil

• A supraventricular tachycardia converts to ventricular flutter after administration of verapamil. The rhythm subsequently degenerates into ventricular fibrillation.
• The rapid deterioration with verapamil suggests that the patient may have underlying Wolff-Parkinson White syndrome.
• In WPW, administration of verapamil or diltiazem during a supraventricular tachycardia may produce a paradoxical increase in ventricular rate by increasing conduction through the accessory pathway. With rapid atrial rhythms such as AF or flutter, the sudden onset of 1:1 AV conduction may produce ventricular rates of >300 beats per minute (i.e. ventricular flutter), which rapidly deteriorates to VF.

Related Topics

• Ventricular Fibrillation
• Ventricular Tachycardia

Further Reading

• ECG BASICS – Waves, Intervals, Segments and Clinical Interpretation
• ECG CLINICAL CASES – Your favourite ECG’s placed in clinical context with a challenging Q&A approach
• ECG and Cardiology Eponymous Syndromes – Cheats guide to eponymous emancipation
• ECG Reference Sites on the WEB – the best of the rest

Author Credits

• Words – John Larkin
• ECG Examples (pictures + interpretations) – Ed Burns
• Web Editing – Ed Burns

References

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
• Jenkins RD, Gerred SJ. ECGs by Example. Second Edition. Elsevier Churchill Livingstone 2005.
• Surawicz B, Knilans TK. Chou’s Electrocardiography in Clinical Practice. 6th Edition. Saunders Elsevier 2008.