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Patient
78-year-old man with a history of pulmonary embolism and chronic cor pulmonale; hospitalization for palpitations (rate of 130 bpm); recording of the electrocardiogram at the time of performing a sino-carotid massage;
Trace
Tachycardia at 130 bpm with wide QRS, right delay, left axis; carotid massage slows the nodal conduction and allows demonstrating a fast, regular and monomorphic atrial activity of 260 bpm; the morphology does not correspond to that of a counterclockwise common flutter; the atrial depolarization wave is positive and broad in the inferior leads with a visible notch in leads II, III but also in aVR; atrial activity is negative in V1 and positive in V6; it is therefore an atrial clockwise flutter of the right atrium with an initial 2:1 conduction with a right bundle branch block and a left anterior fascicular block;
Exergue
The clockwise right atrial flutter pattern includes:
1) an atrial rate usually between 250 and 300 bpm,
2) a positive atrial activation with a notch in the inferior leads,
3) a weak voltage pattern in aVL,
4) a positive component in V6 and negative component in V1.
10% of patients with common flutter episodes also experience clockwise flutter episodes, the right atrial reentry circuit being the same but rotating in the other direction (clockwise).