A logical state model of circus movement atrial flutter. Role of anatomic obstacles, anisotropic conduction and slow conduction zones on induction, sustenance, and overdrive paced modulation of reentrant circuits

Because the relative roles of anatomical obstacles, in combination with functional barriers, anisotropic conduction, and slow conduction can not be readily assessed with current electrophysiological techniques, an atrial activation model was developed to study the mechanisms of circus movement atrial flutter. A discrete state model consisting of 4,096 logically connected cardiac elements was used to simulate atrial activation; an inexcitable region simulating the inferior vena cava (IVC) was also incorporated in the model. Atrial flutter was induced by programmed premature stimulation, Anisotropic conduction velocity properties, regional variations in slow conduction, regional refractory gradients and stimulation parameters were specified for each simulation. The reentrant circuit generally consisted of a single reentrant impulse which circulated around a continuous line of functional bidirectional conduction block joined to the IVC. Rapid pacing, 5-30 ms shorter than the spontaneous reentrant cycle length, was applied to entrain and/or terminate the rhythm. The results of this study demonstrate that patterns of initiation, entrainment, termination and reinitiation of circus movement atrial flutter mimic results from in vivo activation mapping studies. The authors find that sustained circus movement atrial flutter circuits depend on: 1) natural anatomical obstacles to stabilize reentrant circuits, and 2) anisotropic conduction properties to reduce the degree of functional conduction block needed to maintain circus movement. Rapid pacing of simulated circus movement atrial flutter demonstrated that the entrainment criteria can be satisfied in a two-dimensional syncytium.