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Morphological characteristics of P waves during selective pulmonary vein pacing

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

View larger version (17K): [in a new window]   Figure 1 Surface electrocardiogram P waves in one patient with atrial fibrillation (45-year-old man) during pacing at six sites in four pulmonary veins (PVs) are shown. Pacing in left PVs produced P waves with characteristic features of low amplitude in lead I, negativity in lead aVL, similar amplitude in both leads II and III, notched shape in lead II (most evident during left inferior [LI] pacing in this case), and long positive phase in lead V1. In contrast, P waves during right PV pacing were clearly positive in lead I, relatively flat in lead aVL, and had a low amplitude ratio of lead III/II (<0.8). The P waves during superior PV pacing are taller than those of inferior PV pacing in inferior limb leads. A positive P-wave in lead aVL, seen during RI pacing in this case, is a specific marker of right PV origin of pacing. Bottom-LS = bottom of the left superior PV; Bottom-RS = bottom of the right superior PV; RI = right inferior PV; Top-LS = top of the left superior PV; Top-RS = top of the right superior PV.

View larger version (33K): [in a new window]   Figure 2 (A–E) Comparison of the mean amplitude of P waves produced by pacing at six different sites in four pulmonary veins (PVs). (A) In lead I, amplitudes of P waves produced by left PV pacing were significantly lower than those of the right PVs. (B) All six pacing sites produced negative P waves in lead aVR. Pacing in superior sites yielded P waves with more negative amplitudes. (C) In lead aVL, amplitude of P waves increased in a stepwise manner from TLS to RI, and all pacing sites except RI produced negative P waves. (D) In lead II, pacing in superior sites produced P waves with higher amplitudes, whereas P waves paced from similar heights were not significantly different between right and left. Conversely, P waves in lead III during pacing of right PVs were lower in amplitude than those of left PVs paced from a similar height (E). (F) The ratio between the amplitude of leads II and III (III/II ratio) showed values of about 1.0 during left PV pacing, whereas each of the three right PV pacings produced a mean value below 0.8. The dotted horizontal line represents a value of 0.8. *p < 0.05; **p < 0.01. BLS = bottom of the left superior PV; BRS = bottom of the right superior; LI = left inferior PV; RI = right inferior PV; TLS = top of the left superior; TRS = top of the right superior PV.

View larger version (20K): [in a new window]   Figure 3 Algorithm for determining pulmonary vein (PV) origin. The first two criteria (a positive P-wave in lead aVL, higher amplitude of P-wave in lead I greater than 50 µV) and the third criterion (notched shape in lead II) indicate right and left PV origin, respectively with high specificities. Remaining cases are differentiated into right or left according to the amplitude ratio of leads II and III (III/II ratio) or the duration of positive phase in V1. For both right and left veins, P waves taller than 100 µV suggest a superior PV origin. *During pacing/ectopy but absent in sinus rhythm; in the presence of notch in sinus rhythm, go to "No."