GIANT Flutter Waves in ECG Lead V1: a Marker of Pulmonary Hypertension
Address correspondence:James A. Reiffel,
M.D.,161 Fort Washington Ave.,New York, N.Y.
doi : 10.4022/jafib.v1i1.392
Atrial flutter (AFl) may exist with or without underlying
structural heart disease. Typical AFl presents as a “sawtooth” pattern on the
ECG – with inverted flutter (F) waves in the inferior leads and upright F waves
in V1. This morphology offers no direct clues as to the underlying cardiac
disorder, if any. Occasionally we have encountered giant F waves, most
prominently in lead V1, reaching 5 mv or more in height – sometimes exceeding
the QRS voltage. The significance of this pattern has not been investigated
and reported on. To determine if giant F waves in V1 provide any insight into
the presence/type/absence of specific underlying cardiac pathology, the history
of 6 consecutive patients with giant F waves was reviewed. Upon review, the only
factor common to each patient was the presence of or history of pulmonary
hypertension. Right ventricular dilation and/or dysfunction and right atrial
enlargement with or without tricuspid insufficiency were present in each by
echocardiography. Giant F waves appear to occur in the setting of right heart
dysfunction in patients with a history of or the continued presence of
pulmonary hypertension. Their detection should indicate the need for right
Atrial flutter (AFl) is a common arrhythmia  that may occur in the presence or absence of underlying
structural heart disease and may occur in conjunction with or in the absence of
periods of atrial fibrillation [2-4].
Most often, atrial flutter takes the form of a right atrial reentrant
arrhythmia revolving around the RA isthmus in a clockwise or counterclockwise
direction, in which it is referred to a “typical” AFl and produces a “sawtooth”
pattern to the flutter waves – especially in the inferior ECG leads; other
forms morphologically and/or in location have been considered as “atypical”
Among the many structural heart disease alterations to which
AFl has been linked is pulmonary hypertension ,
whether from congenital  or acquired
disorders. However, no specifics of the morphological characteristics of the
flutter in the setting of pulmonary hypertension have been described.
Accordingly, we found it of note that in six consecutive patients who presented
with “giant” flutter waves – 5 mv or greater in height in lead V1, often taller
than the QRS complex in the same lead, each had a common underlying finding:
that of a history of or active presence of pulmonary artery (PA) hypertension
and structural right heart alterations.
The records of six consecutive patients who presented in
atrial flutter with “giant” flutter waves as defined above were reviewed
retrospectively. Patient ages were 36 to 73 years; 5 were women. Each
underwent echocardiography in addition to other tests deemed clinically
necessary in their particular circumstances.
Patient #1 was a 36 year old female with primary pulmonary
hypertension who was treated with an atrial balloon septostomy. Her
pre-procedure PA pressures were 84/48 mm Hg.
Patient #2 was a 38 year old female with idiopathic
pulmonary fibrosis who ultimately underwent lung transplantation. Her
pre-operative PA pressures were 99/52 mm Hg.
Patient # 3 was a 59 year old female with a history of
rheumatic aortic and mitral valve disease who was s/p mechanical mitral and
aortic valve replacement. She also had chronic obstructive pulmonary disease.
Estimated systolic PA pressure by echocardiography was 48 mm Hg.
Patient #4 was a 73 year old female with a history of
rheumatic mitral valve disease, having undergone valvuloplasty in 1954 and eventually
prosthetic valve replacement 50 years later. Her estimated PA systolic
pressure by echocardiography was 45 mm Hg.
Patient #5 was a 37 year old female with primary pulmonary
hypertension who ultimately underwent bilateral lung transplantation. Her
pre-operative PA pressures were 92/49 mm Hg.
Patient #6 was a 62 year old male with a familial
hypertrophic cardiomyopathy and mitral insufficiency who was treated medically.
Her estimated PA systolic pressure by echocardiography was 50 mm Hg.
In each of the 6 patients described, the ECG presentation of
their atrial flutter revealed “giant” flutter waves. None of the patients had
atrial fibrillation in the time frame of their atrial flutter. There was no
underlying left heart disease in the three patients with primary pulmonary
hypertension or idiopathic pulmonary fibrosis. Representative ECGs from three
of the patients are shown [figures 1-3]. In addition to the
presence of “giant” flutter waves on their electrocardiogram, and an underlying
pathology that included the presence of or history of pulmonary hypertension,
each of the patients on echocardiography had findings of right ventricular
dilation and/or mechanical dysfunction and visually assessed right atrial
enlargement. RA planimetry was not routinely performed in all patients. Four
also had more than trace tricuspid insufficiency. Flutter was treated
medically in each patient and none has undergone electrophysiologic study. In
only 1 patient (patient #1) was the flutter “typical” RA isthmus-dependent by
12 lead ECG (not shown).
Atrial flutter is a commonly encountered atrial
tachyarrhythmia. It may occur as an isolated disorder (“lone”) or alternate
with “lone” atrial fibrillation or it may occur in the setting of demonstrable
underlying cardiac disease. To date, however, the magnitude of the flutter
waves on the electrocardiogram has not been a focus of diagnostic interest. In
the six patients we encountered whose data are described above, the magnitude
of the flutter waves in ECG lead V1 was “giant,” that is, 5 mv or more. In each
there was an underlying common finding of primary or secondary pulmonary
hypertension with right ventricular and right atrial enlargement. We have not
encountered “giant” flutter waves in any other setting. Thus, we suggest that
the detection of “giant” flutter waves should indicate a high degree of
suspicion for pulmonary hypertension and right heart pathology and lead to an
appropriate evaluation if not already performed.
1. Lee KW, Scheinman MM. Atrial flutter: a review of its history, mechanisms, clinical features, and current therapy. Current Problems in Cardiology 2005; 30:121-67. CrossRef PubMed
2. Waldo AL, Feld GK. Interrelationships of atrial fibrillation and atrial flutter mechanisms and clinical implications. J. Am. Coll. Cardiol. 2008; 51:779-86. CrossRef PubMed
" 3. Waldo AL. The interrelationship between atrial fibrillation and atrial flutter. Prog. In Cardiovasc Dis 2005; 48:41-56. CrossRef PubMed
4. Calo L, Lamberti F, Loricchio ML, De Ruvo E, Bianconi L, Pandozi C, Santini M. Atrial flutter and atrial fibrillation: which relationship? New insights into the electrophysiological mechanisms and catheter ablation treatment. Ital. Heart J 2005; 6:368-73."
5. Garan H. Atypical atrial flutter. Heart Rhythm 2008; 5:618-21. CrossRef PubMed
6. Cosio FG, Martin-Penato A, Pastor A, Nunez A, Goicolea A. Atypical flutter: a review. PACE 2003; 26:2157-69. CrossRef PubMed
7. Tongers J, Schwerdtfeger B, Klein G, Kempf T, Schaefer A, Knapp JM, Niehaus M, Korte T, Hoeper MM. Incidence and clinical relevance of supraventricular tachyarrhythmias in pulmonary hypertension. Am. Heart J. 2007; 153:127-32. CrossRef PubMed
8. Li W, Somerville J. Atrial flutter in grown-up congenital heart (GUCH) patients. Clinical characteristics of affected population. International J of Cardiology 2000; 75:129-37. CrossRef PubMed