Atrial Flutter: Advances in Mechanisms and Management (review)

Atrial Flutter: Advances in Mechanisms and Management. Edited by Albert L. Waldo and Paul Touboul. Armonk, NY: Futura Publishing Co., 1996. Pp. 480. $109. Our understanding of the electrophysiologic bases of supraventricular arrhythmias has undergone explosive growth in the last decade. This has led to improved pharmacologic, surgical, and, more recently, curative ablative therapy. Atrial flutter is an arrhythmia that over the years has been lumped in clinical studies with the more frequendy encountered atrial fibrillation, but atrial flutter is unique in mechanism and—as is being discovered—in treatment. The editors, Albert Waldo and Paul Touboul, invited a very distinguished group of contributors. Dr. Waldo, now the Walter H. Pritchard Professor of Cardiology at Case Western Reserve University, and his collaborators published a series of classic articles on atrial flutter following open heart surgery, which clarified mechanims, and on entrainment, the resetting of the atrial flutter rate by pacing, which was subsequently generalized to other types ofsupraventricular and ventricular arrhythmias . Paul Touboul is Professor of Cardiology at the Hôpital Cardiologique Louis Pradel in Lyons, France, and has been involved in some of the pioneering work on the ablation of this arrhythmia. The editors, then, are eminenüy qualified for the task at hand. The hope of the editors is "to meet the expectations of both scientists and cardiologists," and, to begin with a conclusion, the editors in large part succeed . The book is organized in nine parts and 35 chapters. The nine parts are an historical introduction, the pathological bases, physiologic determinants, mechanisms based on studies both in animals and humans, clinical aspects, electrocardiography, drug therapy, electrical conversion and long-term control, and ablation techniques. The chapters are concise, and mostly well-written and well-documented. I enjoyed the historical introduction by Dr. Guy Fontaine of the Hôpital Jean Rostand in Ivry, France. Although great figures in the history ofcardiac electrophysiology and electrocardiography appear in the literature of atrial flutter, including MacWilliams, Jolly and Ritchie, Einthoven, Lewis, Rothberger, Scherf, Prinzmetal, Sodi-Palleres, Rosenbluetii and Garcia-Ramos, Peuch and others, the investigation ofthis arrhythmiawas neglected until about 20 years ago. The early and more recent history is nicely reviewed up until about 1993. One could quibble about the exclusion of certain individuals, but this chapter is a useful resource. A major strength of the book is the inclusion of virtually everything one would like to know about atrial flutter. Many of the pathologic, electrophysiologic, and physiologic chapters are written with elegance by major investigators and clinicians with a long interest in atrial flutter. A problem is that a number of chapters seem quite familiar from other books and review publications. While it is useful to gather such material in one cover, several chapters could have focussed better on the topic at hand, namely atrial flutter. I would have liked to have seen a chapter that considers some of the epidemiology , incidence, and natural history of atrial flutter. Some of the data is available, but it is scattered throughout die book. This may not be a problem for the senior cardiologist, but it will be a problem for other physicians and for physicians in training. The point of this book was to focus on atrial flutter, and a major problem in Perspectives in Biology and Medicine, 40, 4 ¦ Summer 1997 | 621 the past has been the "lumping" of atrial flutter and atrial fibrillation. A chapter addressing the similarities, differences, and interrelationships between atrial flutter and atrial fibrillation would have strengthened the book. Related are issues as to whether atrial flutter predisposes to atrial fibrillation in a significant number of individuals, and whether the ablation of atrial flutter affects the recurrence of atrial fibrillation in individuals. The chapter by Samuel Levy of the University ofMarseille in France attempts to address some of the clinical issues, particularly anticoagulation , in individuals with pure atrial flutter. A final problem is that much has happened since the book was put to bed. This is a frequent problem with multi-authored books, which often require much time to compile. Judging from the bibliographies, the literature was current until some time in 1993. 1994, 1995, and 1996 have witnessed an explosion in clinical electrophysiologic understanding and...