Accuracy of new ECG algorithm for Localizing accessory pathway in patients with typital Wolff–Parkinson-White syndrome
1930, Louis Wolff, John Parkinson et Paul Dudley White: The terminology
WPW was first used to described “11 patients with short PR interval and bundle
branch block pattern”, who also suffered with paroxysmal supraventricular
tachycardia and/or atrial fibrillation”→WPW syndrome: Classic WPW
electrocardiogram with short PR ≤ 110 ms, widened QRS > 120 ms, and delta wave
Total (n): 58 51 109 Accuracy of the algorithm for localizing APs in left side or right side pathway by delta wave positive or negative at V1 was very significantly high, giving a sensitivity of 98.3%, specificity of 92.2%, PPV of 93.4% and NPV of 97.9%. 1. Chiang CE., et al. (1995). The American Journal of Cardiology; 76: 40-46 2. Rostock T., et al. (2008). J Interv Card Electrophysiol 22: 55-63 Dar et al. (2008) showed that Se of 97% and Sp of 95% 3.2. Prediction for the septal of free wall location by QRS transition on 12-lead ECG Accuracy of the algorithm for localizing APs in septal or lateral sites pathway by transition characteristics of the QRS complex at V1V2 or after V1V2 was very significantly high, giving a sensitivity of 87.8%, specificity of 97.1%, PPV of 94.7% and NPV of 93% Location of AP Position of transition zone Septal pathway Free wall pathway Total V1V2/V2-V3 36 2 38 After V1V2 ( V3-V6)/before V1 5 66 71 Total (n): 41 68 109 1. Dar MA., et al. (2008) Pakistan Heart Journal 41: 3-4. Table 3.2: The QRS transition on 12-lead ECG for the septal or free wall locations 1. Dar MA., et al. (2008), Pakistan Heart Journal 41: 3-4. 3.3. Prediction for the anterior or posterior location by positive or negative delta waves in at least 2/3 inferior leads Accuracy of the algorithm for localizing APs in anterior or posterior location by positive or negative delta wave in at least 2/3 inferior leads was very significantly higher, giving a sensitivity of 100%, specificity of 88.7%, PPV of 78.6% and NPV of 100%. Muhammad showed that Se and Sp from 85-100%. Location Delta wave polarity in inferior lead Anterior pathway Posterior pathway Total Positive delta wave in at least 2/3 inferior 22 6 28 Negative Delta wave in at least 2/3 inferior 0 47 47 Total (n): 22 53 75 Table 3.3: Positive or negative delta waves in at least 2/3 inferior leads for the anterior or posterior location 3.4. Prediction for the right free wall lateral location Location Delta wave polarity in inferior leads Right Anterolateral (RAL) Right lateral (RL) Right Posterolateral (RPL) Total Positive delta wave in at least 2/3 inferior 9 1 0 10 Negative Delta wave in at least 2/3 inferior 0 4 9 13 Total (n): 9 5 9 23 Diference between RAL region and both RL/RPL region by positive or negative delta wave was most common in at least 2/3 inferior leads was found in 9/9 patients with RAL pathways (100%) and 13/14 RL/RPL pathways (92.9%); Giving a Se 100%, Sp 92.9%, PPV 90%, NPV 100%, R = 0.914 (p < 0.0001) Table 3.4: Delta wave Polarity in at least 2/3 inferior leads 1. Giorgi C., et al. (1990) Am Heart J; 119: 592-598 2. D’ avila A, et al. (1995) PACE; 18: 1615-1627. 3. Taguchi N., et al. (2014) Arrhythmmia; 30 (6): 439-443. 4. Rostock T., et al. (2008) I Interv. Card. Electrophysiol. J.; 10: 292-309. 3.4. Prediction for the right free wall lateral location Location QRS complex polarity in inferior leads Right Anterolateral (RAL) Right lateral (RL) Right Posterolateral (RPL) Total Positive delta wavein at least 2/3 inferior 9 4 2 15 Negative Delta wave in at least 2/3 inferior 0 1 7 8 Total (n): 9 5 9 23 Difference between the RAL/RL and RPL region by positive/negative QRS complex in at least 2/3 inferior leads with high accuracy, giving a Se 92.9%, Sp 77.8%, PPV 86.7%, NPV 87.5%, R = 0.724, p < 0.0001. Difference between the RL and RPL region by positive/negative QRS complex in at least 2/3 inferior leads with high accuracy, giving a Se 80%, Sp 77.8%, PPV 66.7%, NPV 87.5%, R = 0.559, p < 0.05. Table 3.5: QRS complex Polarity in at least 2/3 inferior leads 1. Giorgi C., et al. (199) Am Heart J; 119: 592-598. 2. D’ avila A, et al. (1995) PACE; 18: 1615-1627. 3. Taguchi N., et al. (2014). Arrhythmmia; 30 (6): 439-443. 4. Thomas R, et al (2008). I Interv. Card. Electrophysiol. J.; 10: 292-309. 3.5. Prediction for the left free wall lateral location Location Delta wave polarity in inferior leads Left Anterolateral (LAL) Left lateral (LL) Left Posterolateral (LPL) Total Positive delta wavein at least 2/3 inferior leads 12 25 2 39 Negative Delta wave in at least 2/3 inferior leads 0 0 6 6 Total (n) 12 25 8 45 Difference between both in LAL/LL and LPL region by positive/negative delta waves in at least 2/3 inferior leads was found in very highly accurate. Giving a Se 100%, Sp 75%, PPV 94.9%, NPV 100%. Table 3.6: Delta wave Polarity in at least 2/3 inferior leads 1. Giorgi C., et al. (1990) Am Heart J; 119: 592-598 2. D’ avila, et al. (1995) PACE; 18: 1615-1627. 3. Taguchi N. et al. (2014) Arrhythmmia; 30 (6): 439-443. 4. Rostock T., et al. (2008) I Interv. Card. Electrophysiol. J. ; 10: 292-309. 5. Dar MA., et al. (2008) Pak. Heart. J. ; 41(2): 29-38. 3.5. Prediction for the left free wall lateral location Location R/S ratio in lead V1 Left Anterolateral (LAL) Left lateral (LL) Total 1 R/S ratio > 1 13 14 27 2 R/S ratio < 1 2 34 36 QRS: R morpholgy 2 7 9 Total (n) 17 55 72 Difference between LAL and LL region by R/S > 1 or R/S < 1, R morphology in lead V1 was found in very highly accurate. Giving a Se 91.7%, Sp 76%, PPV 64.7%, NPV 95%. Table 3.6: R/S ratio in lead V1 for the left anterolateral and left lateral 1. Giorgi C., et al. (1990) Am Heart J; 119: 592-598. 2. D’ avila A, et al. (1995) PACE; 18: 1615-1627. 3. Taguchi N., et al (2014) Arrhythmmia; 30 (6): 439-443. 4. Dar MA., et al. (2008) Pak. Heart. J. 41(2): 29-38.. 1. Giorgi C., et al. (1990) Am Heart J; 119: 592-598. 2. Chiang C.E. et al. (1995) Am. J. Cardiol .76: 40-46. 3. D’ avila A., et al. (1995) PACE; 18:1615-1627. 4. Dar M.A.., et al. (2008) Pak. Heart. J. 41(2): 29-38. 3.6. Prediction for the septal location Location R/S ratio in lead V1 Midseptal (MS) No midseptal (RAS, RPS/PLS) Total Qrs pattern (Qrs, qRs, qrS) 3 3 6 No Qrs pattern (Qrs, qRs, qrS) 1 34 35 Total (n) 4 37 41 Difference between midseptal and no midseptal (RAS/RPS/LPL) region by Qrs pattern (Qrs, qRs, qrS) or no Qrs pattern in at least 1/3 inferior leads was found in very significantly higher. Giving a Se 75%, Sp 91.9%, PPV 50%, NPV 97.1%. Table 3.7: R/S ratio in lead V1 for the left anterolateral and left lateral Table 3.8. Sensitivity, Specificity, PPV and NPV Value of the Proposed Algorithm for accessory pathway Site: 3.7. Accuracy of new ECG algorithm for localizing accessory pathways Accessory Pathway Site (n = 109) Se (%) Sp (%) PPV (%) NPV (%) Right side or left side pathways 98.3% 92.2% 93.4% 97.9% Antero or postero accessory pathways 100% 88.7% 78.6% 100% Septal or lateral accessory pathways 87.8% 97.1% 94.7% 93% RAL and RL/RPL region 100% 92.9% 90% 100% RAL/RL and RPL region 92.9% 77.8% 86.7% 87.5% RL and RPL region 80% 77.8% 66.7% 87.5% LAL/LL and LPL 100% 75% 94.9% 100% LAL and LL region by R/S ratio in lead V1 91.7% 76% 64.7% 95% MS and RAS/RPS region 75% 91.9% 50% 97.1% Name of research Accessory pathway location Procedure time (minute) * Radiation time (minute) ** Robert Lemery (1992) WPW (n = 60) 216.0± 90.0’ 66.0± 33.0’ Hugh Calkins (1992) WPW (n = 250) 134.0± 75.0’ 47.0± 33.0’ Dong Van Tran (2006) WPW (n = 96) 117.5± 56.8’ 22.7± 13.4’ Majid Haghjoo (2008) Posteroseptal (n=94) - 40.0 ± 13.0 Schwagten B (2010) WPW (n=94) 87.1± 30.8’ 14.4± 4.7’ Our research (2011-2017) WPW syndrome (n = 298) 52.7±26.3’ 8.3±4.7’ Our (Jan.2011 - May.2016) WPW syndrome (n = 189) 55.0±26.7’ 9.0±5.0’ *p < 0.05, ** p < 0.001 Our (June.2016 – May. 2017) WPW syndrome (n = 109) 48.7 ± 18.5’ 7.2 ± 4.0’ Table 3.9. Compared with other research about radiation time and procedure time : 3.8. Accuracy of new ECG algorithm for localizing accessory pathways 1. Lemery R et al. (1992) Circulation. 85, pp. 957-962.. 2. Calkins H, et al. (1992) Circulation; 85: 1337-1346. 3. Dong VT. (2006) Doctor of Phylosophy Thesis in medicine. VMMU 4. Haghjoo M, Mahmood E, Fazelifar AF, et al. (2008) PACE. 31: 103-111 5. Schwagten B., Ayerza MR .et al. (2010) PACE; 33: 1298-1303 6. Igor S . (1993) Williams & Wilkins, Baltimore: 52-68. Radiation time for per case > 48 minute, > 4 case/per weeks (± cause on chromosomal aberration). We used to the our new algorithm (Figure) was proved to localize accessory pathways with high accuracy (Se and Sp from 75% to 100%); and could facilitate RFCA in patients with left or right side pathways. The role of the potential to predict a successful ablation site can help to the procedure time and fluoroscopy time were significantly shorten, it’s fluoroscopy safety. The new ECG algorithm for localizing accessory pathways Delta wave polarity in V1 Right side: (-) dela wave Left side: (+) delta wave Right free wall: QRS transition at after V1,V2 (V3-V6) Right Septal: QRS transition at V1,V2 Left Septal: QRS transition at V1,V2 Left free wall: QRS transition at after V1,V2 (V3-V6) or before V1 RAL: (+) delta wave and (+) QRS complex in at least 2/3 inferior lead RPL: (-) delta wave and (-) QRS complex in at least 2/3 inferior lead LAL: (+) delta wave in at least 2/3 inferior lead, R/S > 1 in V1 RL: (-) delta wave and (+) QRS complex in at least 2/3 inferior lead LPL: (-) delta wave in at least 2/3 inferior lead LL: (+) delta wave in at least 2/3 inferior lead, R/S < 1 or R RAS: (+) delta wave in at least 2/3 inferior lead, no Qrs in inferior lead RPS: (-) delta wave in at least 2/3 inferior lead, no Qrs in inferior lead RMS: Qrs in inferior lead Step 1 Step 2 Step 3 LPS: (-) delta wave in at least 2/3 inferior lead, no Qrs in inferior lead Re: Si CD., Khanh PQ., Dong TV. (2017) Interv. Cardiol. J.; 9(6): 229-237 Thank you very so much! Dr. Si Dung Chu, MD., Cardiology, Doctorate Handphone: +84 906 086 168 Email: dr.swiss.zhu@gmail.com Question ???
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