Atypical Atrial Flutter

A 68-year-old man presents with sustained atrial flutter. He has a history of bioprosthetic mitral valve replacement and had undergone two prior ablations for atrial fibrillation and flutter that involved pulmonary vein isolation and cavotricuspid isthmus ablation. He was found to have a reentrant right atrial flutter with a critical isthmus ablated in the CTI region. He also had perimitral flutter that was terminated with ablation at the epicardial lateral mitral annulus via the coronary sinus.