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ELECTROPHYSIOLOGY

Morphological characteristics of P waves during selective pulmonary vein pacing

^a Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France

Manuscript received December 5, 2000; revised manuscript received June 21, 2001, accepted July 13, 2001.

^* Reprint requests and correspondence: Dr. Dipen C. Shah, Hôpital Cardiologique du Haut-Lévèque, Avenue de Magellan, 33604 Bordeaux-Pessac, France
jacques.clementy{at}pu.u-bordeaux2.fr

OBJECTIVES

We sought to assess the value of 12-lead electrocardiogram (ECG) P-wave morphology to recognize the paced pulmonary vein (PV).

BACKGROUND

Prediction of arrhythmogenic PVs producing ectopy or initiating atrial fibrillation (AF) using 12-lead ECG may facilitate curative ablation.

METHODS

In 30 patients P-wave configurations were studied during sinus rhythm and during pacing at six sites from the four PVs: top and bottom of each superior PV and both inferior PVs. The P-wave amplitude, duration and morphology were assessed, and predictive accuracies were calculated for the most significant parameters. An algorithm predicting the paced PV was developed and prospectively evaluated in a different population of 20 patients.

RESULTS

Three criteria were used to distinguish right from left PV: 1) a positive P-wave in lead aVL and the amplitude of P-wave in lead I 50 µV indicated right PV origin (specificity 100% and 97%, respectively); 2) a notched P-wave in lead II was a predictor of left PV origin (specificity 95%); and 3) the amplitude ratio of lead III/II and the duration of positivity in lead V₁ were also helpful in distinguishing left versus right PV origin. In addition, superior PVs could be distinguished from inferior according to the amplitude in lead II (100 µV). In prospective evaluation, an algorithm based on the above four criteria identified 93% of left versus right PV and totally 79% of the specific PVs paced.

CONCLUSIONS

Pacing from the different PVs produced a P-wave with distinctive characteristics that could be used as criteria in an algorithm to identify the PV of origin with an accuracy of 79%.

Abbreviations and Acronyms   AF = atrial fibrillation   ECG = electrocardiographic/electrocardiogram   LA = left atrium   NPV = negative predictive value   PPV = positive predictive value   PV = pulmonary vein   RF = radiofrequency

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