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Common Atrial Flutter Sustained by a Right Atrial Circus Movement with Anticlockwise Rotation: The First Demonstration in Humans

In the early 1950s, Paul Puech who was the head of the Cardiology Department in the Centre Hospitalier et Universitaire in Montpellier, France began to study catheter mapping of normal and abnormal propagation of atrial activation. In 1970 Puech, Latour and Grolleau reported their experience with catheter mapping of human atrial flutter in an article titled “Le flutter et ses limites” published in the Archives des Maladies du Cœur et des Vaisseaux. In the introduction of their classic paper, the authors described the prevailing thoughts regarding the mechanism of atrial flutter in the 1960s. Sir Thomas Lewis had been a strong advocate of reentry around the orifices of the caval veins. In this respect, Rosenblueth and Garcia Ramos had advanced a circus movement model of reentry around an artificially created obstacle. Others favored a focal mechanism thereby ignoring the frequent association of atrial flutter with intraatrial conduction disturbances. Puech began his work on atrial mapping in 1953. The 1970 report involved 55 cases of right atrial mapping initially with unipolar catheters, followed by bipolar catheters from 1962 to 1967 and multipolar catheters thereafter. “The left atrium was usually mapped with esophageal electrodes or less commonly via a patent foramen ovale or the coronary sinus. All intracardiac electrograms were recorded simultaneously with surface ECG leads I, II, III, V1, V3 and V6.” Based on surface ECG morphology Puech et al. classified atrial flutter into three groups: