Counterclockwise and (Left) vs Clockwise (Right) Flutter

Typical atrial flutter is counterclockwise in direction and originates from a reentrant circuit around the tricuspid valve annulus and through the cavo-tricuspid isthmus. This results in negatively-directed flutter waves in the inferior leads. At times, the direction of the circuit can reverse, causing clockwise atrial flutter from the same anatomical location. This appears as positively-directed flutter waves in the inferior leads.



Atypical atrial flutter originates from the left atrium or areas in the right atrium (such as surgical scars) and has a variable appearance on ECG in regards to the flutter waves.



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