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CLINICAL RESEARCH

P-Wave Morphology in Focal Atrial Tachycardia

Development of an Algorithm to Predict the Anatomic Site of Origin

Peter M. Kistler, MBBS, PhD^_*,, Kurt C. Roberts-Thomson, MBBS^_*,, Haris M. Haqqani, MBBS^_*,, Simon P. Fynn, MRCP^_*,, Suresh Singarayar, MBBS, PhD^_*,, Jitendra K. Vohra, MD^_*,, Joseph B. Morton, MBBS, PhD^_*,, Paul B. Sparks, MBBS, PhD^_*, and Jonathan M. Kalman, MBBS, PhD^_*,,_*

^_* Department Of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
Department of Medicine, University of Melbourne, Melbourne, Australia

Manuscript received December 9, 2005; revised manuscript received March 22, 2006, accepted March 28, 2006.

^_* Reprint requests and correspondence: Prof. Jonathan M. Kalman, Department of Cardiology, Royal Melbourne Hospital, Royal Parade, Parkville, Victoria 3050, Melbourne, Australia 3050 (Email: jon.kalman{at}mh.org.au).

This work is presented in part and is a recipient of the Eric and Bonny Prystowsky Heart Rhythm Society Fellows Clinical Research Award, New Orleans, Louisiana, 2005.

OBJECTIVES: The purpose of this study was to perform a detailed analysis of the P-wave morphology (PWM) in focal atrial tachycardia (AT) and construct and prospectively evaluate an algorithm for identification of the anatomic site of origin.

BACKGROUND: Although smaller studies have described the PWM from particular anatomic locations, a detailed algorithm characterizing the likely location of a tachycardia associated with a P-wave of unknown origin has been lacking.

METHODS: The PWMs for 126 consecutive patients undergoing successful radiofrequency ablation of 130 ATs are reported. P waves were included only when the onset was preceded by a discernible isoelectric segment. P waves were classified as positive (+), negative (–), isoelectric, or biphasic. Sensitivity, specificity, and predictive values were calculated. On the basis of these results, an algorithm was constructed and prospectively evaluated in 30 new consecutive ATs.

RESULTS: The distribution of ATs was right atrial (RA) in 82 of 130 (63%) and left atrial (LA) in 48 of 130 (37%). Right atrial sites included crista (n = 28), tricuspid annulus (n = 29), coronary sinus (CS) ostium (n = 14), perinodal (n = 7), right septum (n = 1), and RA appendage (n = 3). Left atrial sites included pulmonary veins (n = 32), mitral annulus (n = 8), CS body (n = 3), left septum (n = 3), and LA appendage (n = 2). In electrocardiographic lead V₁, a negative or +/– P-wave demonstrated a specificity of 100% for a RA focus, and a + or –/+ P-wave demonstrated a sensitivity of 100% for a LA focus. A characteristic PWM was associated with high sensitivity and specificity at common atrial sites for tachycardia foci. A P-wave algorithm correctly identified the focus in 93%.

CONCLUSIONS: Characteristic PWMs corresponding to known anatomic sites for focal AT are associated with high specificity and sensitivity. A P-wave algorithm correctly identified the site of tachycardia origin in 93%.

Abbreviations and Acronyms   AT = atrial tachycardia   CS = coronary sinus   CT = crista terminalis   ECG = electrocardiogram   LA = left atrium   LAA = left atrial appendage   LIPV = left inferior pulmonary vein   LSVP = left superior pulmonary vein   MA = mitral annulus   NPV = negative predictive value   PPV = positive predictive value   PV = pulmonary vein   PWM = P-wave morphology   RA = right atrium   RAA = right atrial appendage   RFA = radiofrequency ablation   RIPV = right inferior pulmonary vein   RSPV = right superior pulmonary vein   SR = sinus rhythm   SVC = superior vena cava   TA = tricuspid annulus

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