An Accurate Stepwise Electrocardiographic Algorithm for localization of Accessory Pathways in Patients With Wolff-Parkinson-White Syndrome from a Comprehensive Analysis of Delta Waves and R/S Ratio During Sinus Rhythm

doi:10.1016/S0002-9149(99)80798-X

The American Journal of Cardiology

Volume 76, Issues 1–2, July 1995, Pages 40-46

https://doi.org/10.1016/S0002-9149(99)80798-X Get rights and content

Prediction of accessory pathway location before radio-frequency ablation has become increasingly important for patients with Wolf-Paridnson-White syndrome. However, existing electrocardiographic (ECG) criteria for localization of accessory pathways have several limitations, and the polarity of delta waves has not been well defined. In the present study, 369 patients with a single anterogradety conducting accessory pathway who underwent successful radiofrequency ablation were included. The polarity of delta waves was defined and categorized in detail, and various ECG characteristics of the most preexcited QRS complexes were examined and compared with QRS complexes after successful ablation in the initial 182 patients, which included morphology and polarity of delta waves, initial 20, 40, and 60 ms segments of the preexcited QRS complex, R/S ratio in the precordial leads, R/S ratio in the frontal leads, delta wave axis in the frontal plane, polarity of delta waves in the frontal leads, and polarity of delta waves in the precordial leads. The polarity of the initial 40 ms segment of the most preexcited QRS complexes in each of the frontal leads, and the polarity of the initial 60 ms segment of the most preexcited QRS complex in each of the precordial leads proved to be the best representatives of delta wave polarity in the respective leads. The most discriminative characteristics were combined to form the following algorithm: step 1, analysis of R/S ratio in V₂; step 2, existence of positive delta wave in lead III (initial 40 ms); step 3, existence of positive or negative delta waves in V₁, (initial 60 ms); and step 4, delta wave polarity in aVF or analysis of R/S ratio in V₁. The new algorithm is featured by its easiness to be applied because only 4 ECG leads and 4 steps are required, and the same ECG characteristic is used in the same step in both arms of the algorithm. Together with 3 other criteria (those of Arruda, Filzpatrick, and Xie), it was prospectively evaluated in 187 subsequent patients, and it turned out to be more accurate (93%) than other algorithms (86%, 86%, 85%, respectively; all p values <0.05). We conclude that this new algorithm, through a comprehensive analysis of delta waves and an R/S ratio in a large group of patients, offers an accurate criterion for predicting accessory pathway location.

Section snippets

Methods

Patients: In all, 393 consecutive patients with Wolff-Parkinson-White syndrome were referred for electro-physiologic study and radiofrequency ablation. Sixteen patients with multiple accessory pathways and 8 with unsuccessful radiofrequency ablation were excluded. Three hundred sixty-nine patients who were proved to have a single anterogradely conducting accessory pathway by successful radiofrequency ablation formed the subject of this study. There were 219 men and 150 women (mean age 48 ± 10

Results

Accessory pathway location: The accessory pathway location in the initial 182 patients is shown in Figure 2.

Eledrocardiographic characteristics: Both observers agreed that electrocardiograms for right anteroseptai and right anterior pathways were very similar and could not be differentiated, as were right posterior and right posterolateral pathways, left posterior and left posterolateral pathways, and left lateral and left anterolateral pathways. They were designated as right anteroseptal/right

Discussion

By a comprehensive analysis of delta wave polarity and R/S ratio, and a new definition of the initial 60 ms to represent delta wave polarity in V₁, we developed an accurate ECG algorithm to predict the location of an accessory pathway in patients with Wolff-Parkinson-White syndrome during sinus rhythm. The algorithm was entirely based on the results from radiofrequency ablation and was featured by its easiness to be applied, because only 4 ECG leads and 4 steps were required, and the same ECG

Acknowledgment

We thank Benjamin Ing-Tiau Kuo, MD, for his assistance in statistical analysis.

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Cited by (107)

EPM algorithm: A stepwise approach to accessory pathway localization in ventricular pre-excitation
2024, Journal of Electrocardiology
Accurate estimation of accessory pathway (AP) localization in patients with ventricular pre-excitation or Wolff-Parkinson-White (WPW) syndrome remains a diagnostic challenge. Existing algorithms have contributed significantly to this area, but alternative algorithms can offer additional perspectives and approaches to AP localization.
This study introduces and evaluates the diagnostic accuracy of the EPM algorithm in AP localization, comparing it with established algorithms Arruda and EASY.
A retrospective analysis was conducted on 138 patients from Hospital São Paulo who underwent catheter ablation. Three blinded examiners assessed the EPM algorithm's diagnostic accuracy against the Arruda and EASY algorithms. The gold standard for comparison was the radioscopic position of the AP where radiofrequency ablation led to pre-excitation disappearance on the ECG.
EPM showed a diagnostic accuracy of 51.45%, closely aligning with Arruda (53.29%) and EASY (44.69%). Adjacency accuracy for EPM was 70.67%, with Arruda at 66.18% and EASY at 72.22%. Sensitivity for EPM in distinguishing left vs. right APs was 95.73%, with a specificity of 74.33%. For identifying septal vs. lateral right APs, EPM sensitivity was 82.79% with a specificity of 46.15%. These measures were comparable to those of Arruda and EASY. Inter-observer variability was excellent for EPM, with Kappa statistics over 0.9.
The EPM algorithm emerges as a reliable tool for AP localization, offering a systematic approach beneficial for therapeutic decision-making in electrophysiology. Its comparable diagnostic accuracy and excellent inter-observer variability underscore its potential clinical applicability. Future research may further validate its efficacy in a broader clinical setting.
A novel feature extraction method for the localization of accessory pathways in patients with Wolff-Parkinson-White syndrome
2024, Biomedical Signal Processing and Control
The localization of accessory pathways (APs) in patients with Wolff-Parkinson-White (WPW) syndrome using surface electrocardiogram (ECG) is often entirely subjective. This study aimed to develop a novel, more automated, and non-invasive localization method to differentiate right and left APs.
The participants were 31 patients (aged 8–69 y, mean age: 31.19 ± 14.69 y, 32.3 % women) with manifest WPW syndrome who were treated successfully in the first ablation session. The novel localization of APs was based on feature extraction using McSharry’s model, and SFS-LOV, a combination of three methods (sequential forward selection (SFS), leave-one-subject-out cross-validation (LOSO), and majority voting). The k-nearest neighbor (KNN) and support vector machine (SVM) classifier were separately used in the SFS-LOV method. In this method, the features were extracted from three segments of the ECG signals. Each segment was started from the onset of the P-wave and terminated with the offset of the T-wave. The majority voting was applied to the results of the classifier on the segments of each participant.
The proposed method differentiated the right from the left APs with an accuracy of 87% (sensitivity: 80%, specificity: 94%). This was achieved by feeding four selected parameters of McSharry’s model into the KNN classifier. These selected parameters were estimated from the lead V4 of the ECG signals.
The parameters of McSharry’s model can semi-automatically localize the right and left APs in patients with manifest WPW syndrome.
V1r + DIIq is a novel and accurate criterion to predict right vs. left paraseptal accessory pathways
2022, Journal of Electrocardiology
Citation Excerpt :
In our study, right paraseptal right APs were the most common form of paraseptal APs (62% of all paraseptal APs). The polarity and morphology of delta waves and the QRS complex have been used to estimate AP localization by different ECG algorithms [5–10]. In the Arruda algorithm, paraseptal APs were not divided into right and left sides [5].
The correct estimation of accessory pathway (AP) localization from surface ECG is critical before the procedure. Our study aimed to detect the predictive value of the V1r + DIIq criterion for differentiating right- from left-sided paraseptal APs.
We retrospectively included 58 patients with (Wolff–Parkinson–White) WPW syndrome and paraseptal APs who underwent successful catheter ablation (37 male, 21 female; mean age 34.4 ± 13.6 years). The V1r + DIIq criterion was calculated using the following formula: V1r + DIIq (mV) = initial r wave amplitude in V1 + q wave amplitude in DII. The combined criterion included V1r + DIIq <2.05 mV and/or no initial r wave in V1.
Right-sided paraseptal APs were detected in 36 patients (62.1%), left-sided paraseptal APs were detected in 21 patients (36.2%), and AP from CS was detected in 1 patient (1.7%). The initial r wave amplitude in V1 (mV), q wave amplitude in DII (mV) and V1r + DIIq criterion (mV) were lower in patients with right-sided paraseptal APs (p < 0.001). The percentage of patients with no initial r wave in V1 (36.1% vs. 0%) and those meeting the combined criterion (91.7% vs. 4.5%) were increased in patients with right-sided paraseptal APs. The cutoff value of the V1r + DIIq criterion obtained by ROC curve analysis was 2.05 mV for predicting right-sided paraseptal APs (sensitivity: 86.1%, specificity: 95.5%). The area under the curve (AUC) was 0.943 (95% CI = 0.881–1.000) (p < 0.001). The sensitivity and specificity values were 36.1% and 100%, respectively, for the no initial r wave criterion and 91.7% and 95.5%, respectively, for the combined criterion.
The V1r + DIIq criterion and the combined criterion represent novel and simple electrocardiographic criteria for accurately differentiating right- from left-sided paraseptal APs. This simple ECG measurement can improve the accuracy of detection of paraseptal AP localization and could be beneficial for decreasing ablation duration and radiation exposure.
Endocavitary electrophysiological study by percutaneous antecubital vein and without X-ray for risk stratification of asymptomatic ventricular pre-excitation in young athletes
2021, IJC Heart and Vasculature
Citation Excerpt :
In contrast, the remaining 28 patients (47%) met at least one criterion for ablation: 82% (23 of 28) had rapid antegrade conduction on the AP and 64% (18 of 28) had at least one AVRT inducible (orthodromic in 17 patients and antidromic in 1). The predicted locations of the APs assessed on the surface ECG during maximum pre-excitation [13] were: antero-septal in 2 patients, mid-septal in 4, right postero-septal in 9, left postero-septal in 8, left posterior in 4, left posterolateral in 9, left lateral in 19 and left anterolateral in 5 patients (Fig. 7). ESnoXr has been shown to be a feasible, effective, safe and well tolerated procedure for risk assessment in a population of young athletes (10–18 year-old) with asymptomatic VP that persisted during stress testing referred for risk stratification and evaluation of competitive sport eligibility.
Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.
New algorithm for accessory pathway localization focused on screening septal pathways in pediatric patients with Wolff-Parkinson-White syndrome
2020, Heart Rhythm
Published algorithms for accessory pathway localization in Wolff-Parkinson-White (WPW) syndrome are inaccurate in pediatric patients, especially for septal pathways.
We aimed to develop a new algorithm that is sensitive for septal pathways and more applicable in pediatric patients.
In 120 patients (mean age: 11.7 ± 3.9 years) who underwent catheter ablation for WPW syndrome, the candidate criteria for new algorithm were searched by comparing electrocardiography parameters and accessory pathway locations. A new algorithm was designed to increase the sensitivity for septal pathways. For validation, 142 patients (mean age: 15.8 ± 3.7 years) were additionally evaluated. New and published algorithms were applied to electrocardiography of 262 patients and the results were compared.
The new algorithm achieved its best discrimination by combining several parameters together in each step: (1) QRS polarity in V₁ and QRS shape in lead I for left/right discrimination, and (2) delta wave polarity in V₁, QRS transition in precordial leads, and delta wave polarity in lead III for septal pathway screening. The new algorithm showed higher sensitivity for septal pathways (95.7%) than 7 published algorithms (average: 62.1%), with satisfactory positive predictive value (77.9%). Delta wave polarity in V₁ among septal pathways and QRS axis among right anteroseptal pathway showed age-related trend; this could be the reason for the lower accuracy in localizing septal pathways in children.
The inaccuracy of published algorithms in pediatric patients is due to the age-related trend in the electrocardiography of septal pathways. The new algorithm was superior for localizing septal pathways in pediatric patients.
Algorithms to Identify Accessory Pathways' Location on the 12-Lead Electrocardiogram
2020, Cardiac Electrophysiology Clinics

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^⋆: This study was supported in part by Grants NSC 81–0412-B075–525, 82–0115-B075–110, and 83-0412-B075-028 from the National Science Council and the Academia Sinica, Taipei, Taiwan, Republic of China.

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An Accurate Stepwise Electrocardiographic Algorithm for localization of Accessory Pathways in Patients With Wolff-Parkinson-White Syndrome from a Comprehensive Analysis of Delta Waves and R/S Ratio During Sinus Rhythm⋆

Section snippets

Methods

Results

Discussion

Acknowledgment

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Prog Cardiovasc Dis

J Am Coll Cardiol

Am Heart J

J Electrocardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current

N Engl J Med