Wandering Atrial pacemaker

                                       Wandering Atrial pacemaker


Wandering atrial Pacemaker is an arrhythmia consider the normal variant EKG in normal heart and wealthy person and differ from sinus arrhythmia .

the mechanism of the  arrhythmia is believed to fluctuation of vagal tone that result in arrhythmia .
In this case the sino-atrial (SA) pacemaker transfer to other latent pacemaker in atrial (other site of SA pacemaker) and move to AV junction and than move back to SA and these circle is continue to maintain that rhythm . This variable pacemaker site changes believe the result of vagal tone fluctuation and in consequence these different pacemakers produce different formes of P wave, variable PR interval and Irregular of RR interval  .  
Wandering Atrial pacemaker is called when the heart rate is less than 100 beats per minute .

 When it over 100 beates per minute than we call Multifocal Atrial Tachycardia (clickhere to see it)  ( Arrhythmia that has many P waves morphology and irregularly irregular RR Interval ) that frequently confuse with Atrial fibrillation(afib) .

Please don't confuse frome irregularly irregular to irregular regular rhythm
        In irregularly irregular rhythm we have 3 majors arrhythmia that we have to consider rapidly
                1. Atrial fibrillation (clickhere to see it)
                2. Atrial flutter with variable conduction ( variable conduction of AV node ) (clickhere to see)
                3. Mutifocal Atrial Tachycardia ( MAT)
      In irregular regular rhythm we have
                1. second degree AV block
                2. premature beat (click here to see PAC)


All the conduction abnormality will discus respectively .

Now skip all that thing we go to Wandering atrial pacemaker
  the criteria for WAP are
     Rate < 100 beats per minute
     Rhythm irregularly irregular
     At lease 3 different P wave forme
     PR interval variable  

Other case of WAP

                                                             

Atrial Flutter

                                                          Atrial Flutter


Atrial Flutter is a supra ventricular tachycardia , it mean that narrow complex QRS tachycardia like other supra ventricular tachycardia except aberrant conduction  withe wide complex .

This arrhythmia cause by a circuit reentrant around the tricuspide valve in the right atrium.
Like other SVT the re-entrant circuit is initiated   by premature atrial beat  cause some part of the circuit in refractory state and other can conduce the electrical impulse, so this part conduce  to the refractory area that just recovery, so it form the cycle of conduction and this conduction turn over and over to make the circuit  of re-entrant ,this circuit conduce the fast rate of electrical signal so it cause fast atrial activity that we see on surface ECG rapid atrial activity (many many P wave).

This figure show you the re entrant of Atrial flutter locate at the right atrial compare to Atrial fibrillation that is chaos electrical activity in  both atriums. and also show the direction of the re entrant that counterclockwise direction,that will show P wave invert in DII DII AVF and up right in V1,  that we called typical flutter. In contrast if the direction ogf the circuit is clockwise we call atypical flutter result in  P wave positive in DII DIII AVF and negative in V1.

Here EKG show the typical and atypical flutter

The most common rate of atrial flutter with atrial rate around 300 per minute and the conduction throw the AV node with 2:1 ratio result in ventricular rate about 150 beats per minute . Like that the ventricular rate depend on AV node conduction it can 2:1,3:1or 4:1 or can be greater with 1:1 conduction that cause very fast ventricular rate.

The typical and atypical flutter can occur in same patient

Voila the atrial flutter criteria 

     1 . rate : Atrial rate 250-350 bpm, Ventricular rate variable (depend on AV conduction )

     2 .Rhythm : Atrial regular      , Ventricular variable (depend on AV conduction )

     3 .P wave : Flutter wave ''saw toothed appearance''

     4 .PR interval : Variable

     5 .QRS         : Narrow , wide if F wave buried in QRS 

Here some EKG of Atrial flutter 

The ECG
 C, D  show Atrial flutter with atrial rate about 300 per minute with variable conduction result in                irregularly irregular RR interval
A : show the constant conduction of AV node 2:1 ration and regular of RR interval.
B : show the irregular regular conduction 

This EKG show atrial flutter with 2:1 conduction, and flutter with 1:1 ratio conduction result in very fast of ventricular rate

Another cases  Please try to interpretation all  EKG below