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

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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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