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GIANT Flutter Waves in ECG Lead V1: a Marker of Pulmonary Hypertension

Atrial flutter (AFl) may exist with or without underlying structural heart disease.  Typical AFl presents as a “sawtooth” pattern on the ECG – with inverted flutter (F) waves in the inferior leads and upright F waves in V1.  This morphology offers no direct clues as to the underlying cardiac disorder, if any.  Occasionally we have encountered giant F waves, most prominently in lead V1, reaching 5 mv or more in height – sometimes exceeding the QRS voltage.  The significance of this pattern has not been investigated and reported on.  To determine if giant F waves in V1 provide any insight into the presence/type/absence of specific underlying cardiac pathology, the history of 6 consecutive patients with giant F waves was reviewed. Upon review, the only factor common to each patient was the presence of or history of pulmonary hypertension.  Right ventricular dilation and/or dysfunction and right atrial enlargement with or without tricuspid insufficiency were present in each by echocardiography.  Giant F waves appear to occur in the setting of right heart dysfunction in patients with a history of or the continued presence of pulmonary hypertension.  Their detection should indicate the need for right heart evaluation.




Credits: James A. Reiffel, MD

Biosense Webster
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Introduction to AFib
Ablation Specialist

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