Development and validation of a new algorithm in localizing accessory pathway in typical wolffparkinson - white syndrome

Nội dung text: Development and validation of a new algorithm in localizing accessory pathway in typical wolffparkinson - white syndrome

1. Journal of military pharmaco-medicine N o7-2017 DEVELOPMENT AND VALIDATION OF A NEW ALGORITHM IN LOCALIZING ACCESSORY PATHWAY IN TYPICAL WOLFF- PARKINSON-WHITE SYNDROME Chu Dung Si*; Pham Quoc Khanh**; Tran Van Dong** SUMMARY Objectives: To develop a simple algorithm for localizing accessory pathways (APs) in the typical Wolff-Parkinson-White (WPW) syndrome using 12-lead electrocardiogram (ECG) and to test the accuracy of the newly built algorithm prospectively. Subjects and methods: 298 patients with typical WPW syndrome were enrolled. The ECG parameters of 189 patients with a single anterograde AP that were confirmed by successful radio frequency (RF) catheter ablation were analysed to build a new ECG algorithm for localizing APs. Then this algorithm was tested prospectively in other 109 patients comparing with the localization of APs by RF ablation. Results: In 189 patients analyzed: the sensitivity and specificity of Delta wave polarity in V1 in predicting left or right APs were 98.3% and 92.2%, respectively; the sensitivity and specificity of QRS transition in predicting septal or lateral APs were 87.8% and 97.1%, respectively; the sensitivity and specificity of Delta wave polarity in inferior leads in predicting anterior or posterior APs were 100% and 88.7%, respectively. The validation of the new algorithm based on the above ECG parameters in other 109 patients showed the sensitivity of 87.8% and the specificity of 100%. Conclusion: Delta wave polarity in V1 and inferior leads combined with QRS complex transition were used to develop a new ECG algorithm for localizing AP. This new algorithm can be used to localize accessory pathways with high accuracy. * Keywords: Wolff-Parkinson-White syndrome; Algorithm; 12-lead electrocardiogram. INTRODUCTION RCFA and x-ray procedure [2]. Some algorithms based on ECG criteria have Wolff-Parkinson-White (WPW) syndrome been published to predict locations of associated with an accessory AV connection (called Kent Bundle); the 12-lead ECG is accessory pathways. However, many characterized by a shortened PR, studies were known to be difficult to prolonged QRS, with Delta wave [1, 2]. ablate as compared to those in other locations, some ECG algorithms had Nowadays, radiofrequency catheter difficult parameters in using or only for ablation (RCFA) of accessory pathway (AP) requires precise localization of the some locations. Therefore, the purpose of AP along the mitral and tricuspid annulus this study was to: Analyze the 12-lead (gold standard) [2]. 12-lead ECG is the ECG of accessory pathway localization’s first step for localization of AP in patients successful RCFA to develop new ECG with WPW syndrome, still now. The data algorithm using simple parameters and obtained from the ECG parameters can test this algorithm to predict accessory be helpful in planning and shortening the pathway location. * School of Medicine and Pharmacy, Vietnam National University, Hanoi ** Vietnam Heart Institute, Bachmai Hospital Corresponding author: Chu Dung Si (chudungsi@gmail.com) Date received: 25/06/2017 Date accepted: 11/08/2017 58
2. Journal of military pharmaco-medicine n o7-2017 SUBJECTS AND METHODS Then this algorithm was tested prospectively in 109 patients and 1. Subjects. compared with the location of accessory 298 patients from Jannuary, 2001 to pathway’s successful ablation by RF from May, 2017 at Vietnam Heart Institute, June, 2016 to May, 2017. Bachmai Hospital. WPW syndrome which was defined as 2. Methods. the 12-lead ECG was characterized by a shortened PR interval < 120 milliseconds, Observational, cross-sectional, retrospective prolonged QRS duration ≥ 110 milliseconds and prospective study. with a Delta wave. Secondary ST and T 189 patients with typical WPW syndrome wave changes which are directed who had a single anterograde AP opposite to the major Delta wave and identified by successful radio frequency QRS vector [1]. Localization of accessory catheter ablation were enrolled to build a pathways was identified by successfully new ECG algorithm for localizing APs ablated by RCFA (gold standard) [2]. using simple parameters from January, * Statistical analysis: Using IBM SPSS 2001 to June, 2016. 21.0 software for analyzing data. RESULTS The study population consists of 298 patients, 155 males (52%) and 143 females (48%), with mean age of 43.0 ± 14.7 years (from 18 to 80 years of age). 1. Characteristics of 12-lead ECG for localization of accessory pathways. The study population consists of 189 patients (group I), 99 males (52.4%) and 90 females (47.6%) with mean age of 42.7 ± 14.6 years. 5 (2.6%) 17 (9.0%) 9 (4.8%) 6 (3.2%) RL 10 (5.3%) 25 (13.2%) 55 (29.1%) 29 12 (6.3%) 21(11.1%) (15.3% ) Figure 1: Results of normal annulus position of location (group I). (LA: Left anterolateral; LL: Left lateral; LP: Left posterolateral; LPS: Left posterolateral; RPS: Right posterlateral; RP: Right posterolatearal; RL: Right lateral; RA: Right anterolateral; RAS: Right Anteroseptal; RMS: Right midseptal) 59
3. Journal of military pharmaco-medicine N o7-2017 Among 189 accessory pathways, left Anterior group had Delta wave (+) that sided accessory pathway was found in 109 was most common at least 2/3 inferior patients (57.7%) and right sided accessory lead, was found in 31/31 patients (100%) pathways in 80 patients (42.3%). We and posterior group had Delta wave (-) found that 65 patients (34.4%) had septal that was most common at least 2/3 inferior accessory pathways, 84 patients (44.4%) lead found in 81/87 patients (93.1%). had left free wall sites and 40 patients 2. Accuracy of new ECG algorithm (21.2%) had right free wall sites. for localizing accessory pathways. * Characteristics of Delta wave polarity The study population consists of 109 in V1 lead with left or right side accessory patients (group II), 56 males (51.4%) and pathways: 53 females (48.6%) with mean age of Left side group had positive Delta 43.6 ± 14.9 years. wave that was most common at V1 lead Among 109 patients, accessory was found in 106/109 patients (97.2%) pathways was most common location as and right side group had negative Delta left sided accessory pathways was found wave that was most common at V1 lead in 57 patients (52.3%) and right sided was found in 67/80 patients (83.8%). accessory pathways had 52 patients * Transition characteristics of the QRS (47.7%). Right side free wall was complex on 12-lead ECG with location: 23 patients (21.1%): 9 patients (8.3%) Classified transition of septal location had anterolateral, 5 patients (4.6%) had was most common at V1, V2 lead right lateral and 9 patients (8.3%) had (between V2 and V3) found in 58/65 right posterolateral. Left side free wall was patients contributing 89.2% among total 45 patients (41.3%): 12 patients had number of septal AP. While classified anterolateral, 25 patients (24.0%) had left transition of lateral free wall location was lateral and 8 patients (7.3%) had left most common at after V1, V2 (V3 - posterolateral. Septal accessory V6)/before V1 found in 108/124 patients pathways was found in 41 patients contributing 87.1% among total number of (37.6%): 23 patients (21.1%) had right lateral location. posteroseptal, 13 patients (11.9%) had * Characteristics of Delta wave polarity left posteroseptal, 4 patients (3.7%) had in at least 2/3 inferior lead with anterior or midseptal, 1 patients (0.9%) had posterior group: anteroseptal. * Localization of left or right side accessory pathways by Delta wave polarity in V1 lead: Table 1: Delta wave positive/negative in V1 with left/right accessory pathways. Location Left side pathway Right side pathway Total Delta wave polarity at V1 Positive Delta wave at V1 57 4 61 Negative Delta wave at V1 1 47 48 Total (n) 58 51 109 60
4. Journal of military pharmaco-medicine n o7-2017 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%. * Localization of septal of free wall accessory pathways group by transition characteristics of the QRS complex on 12-lead ECG: Table 2: Transition characteristics of the QRS complex with septal or lateral locations. Location of AP Septal Free wall Total Position of transition zone pathway pathway V1, V2/V2 - V3 36 2 38 After V1, V2 ( V3 - V6)/before V1 5 66 71 Total (n) 41 68 109 Accuracy of the algorithm for localizing APs in septal or lateral sites pathway by transition characteristics of the QRS complex at V1, V2 or after V1, V2 was very significantly high, giving a sensitivity of 87.8%, specificity of 97.1%, PPV of 94.7% and NPV of 93%. * Localization of anterior or posterior accessory pathways group by the Delta wave polarity in at least 2/3 inferior lead on 12-lead ECG: Table 3: Delta wave polarity in at least 2/3 inferior lead (DII, DIII, aVF). Location Anterior Posterior Total pathway pathway Delta wave polarity in inferior lead 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 Accuracy of the algorithm for localizing APs in anterior or posterior sites by positive or negative Delta wave at V1 was very significantly higher, giving a sensitivity of 100%, specificity of 88.7%, PPV of 78.6% and NPV of 100%. Overall, accuracy of new ECG algorithm for localizing accessory pathways sites were high accuracy. Table 4: Sensitivity, specificity, PPV and NPV value of the proposed algorithm for accessory pathway site in 109 patients. Accessory pathway site (n = 109) Se (%) Sp (%) PPV (%) NPV (%) Right side or left side pathways 98.3% 92.2% 93.4% 97.9% Anterior or posterior accessory pathways 100% 88.7% 78.6% 100% Septal or lateral accessory pathways 87.8% 97.1% 94.7% 93% 61
5. Journal of military pharmaco-medicine N o7-2017 DISCUSSION (89.2%). While lateral free wall location pathway was most common at after that 1. Characteristics of Delta wave are noted (87.1%). polarity in V1 lead with left or right septal. Some algorithms based on ECG not- Characteristics of electrocardiogram in yet finding different between anteroseptal a patient with left side pathway had with right anterolateral APs, difficult in strongly positive Delta waves at V1 lead posteroseptal with posterolateral (left or are noted (97.2%) while right side pathway right). However, many studies showed had strongly negative Delta waves at V1 that transition of QRS complex can be leasd are noted (83.8%). used to predict locations of septal or free This is very useful in selecting the wall accessory pathway [1, 5, 6]. approach of the catheter which is the vein 3. Characteristics of Delta wave or artery. All right-sided AP were ablated polarity in at least 2/3 inferior lead with the use of transvenous atrial approach (DII, DIII, aVF) with anterior or posterior through the femoral vein while left-side AP group. AP were ablated with retrograde arterial approach. If this approach failed, the Characteristics of electrocardiogram in pathway was ablated by using antegrade a patient with anterior group pathway had transeptal approach [2]. strongly positive Delta waves in at least Some ECG algorithms have been 2/3 inferior that are noted (100%). While published to predict locations of left-sided posterior group pathway had strongly or right-sided accessory pathway by negative Delta waves in at least 2/3 positive of negative Delta wave [1, 2]. inferior leads (II, III, aVF) are noted (93.1%). Besides, some other studies showed that Some ECG algorithms have been diagnosis of left or right-side accessory published to predict locations of anterior pathway by other ECG parameters such or posterior accessory pathway by as Noriko was used with R/S ratio < 0.5 or positive or negative Delta wave in inferior R/S > 0.5 in V1 lead that can be predicted as below [1, 6, 7]. However, some studies right or left-side AP [3] and D’ Avila was only focused on some positions in anterior used to positive or negative QRS complex and posterior accessory [7]. in V1 that can be diagnosed left or right- side AP [4]. 4. Accuracy of new ECG algorithm 2. Transition characteristics of the for localizing accessory pathways. QRS complex on 12-lead ECG with We developed a new algorithm using septal or lateral location. some simple ECG parameters as left side Characteristics of electrocardiogram in or right side pathways by positive/ a patient with septal location pathway was negative Delta wave at V1 lead, anterior most common at V1, V2 lead are noted or posterior sites accessory pathways by 62
6. Journal of military pharmaco-medicine n o7-2017 positive/negative Delta waves in at least location was most common at after V1 2/3 inferior, septal or lateral sites V2(V3 - V6)/before V1 (87.1%). Anterior accessory pathways by transition QRS group with positive Delta wave was most complex at V1, V2 or after V1, V2 lead. common at least 2/3 inferior lead (100%) and posterior group with negative Delta Then this algorithm was tested wave was most common at least 2/3 prospectively in 109 patients comparing with the location of accessory pathway’s inferior lead (93.1%). successful ablation by RF. Calculation for The new algorithm was proved to be sensitivity, specificity, PPV and NPV of the high accuracy as sensitivity (from 87.8% diagnosed algorithm for accessory pathway to 100%), specificity (88.7 to 97.1%), sites were high accuracy (table 3, 4) . positive predictive value (78.6% to 94.7%) For the left side or right side pathways and negative predictive value (93% to by positive/negative Delta wave at V1 100%) and could facilitate radiofrequency ablation in patients with left side or right lead; Chern-En Chang (1995) showed sided AP. that Se of 94.4% and Sp of 87.5% [8]; Thosmas Rostock proposed to left side of REFERENCES right side pathways by R/S ratio on V1, 1. Borys Surawicz et al. Chou’s aVR, aVL with Se of 95%, Sp of 100% electrocardiography in clinical practice: adult and PPV of 98% [9]. Septal or lateral and pediatric. Elservier Saunders. 2008. accessory pathways by transition QRS 2. Basiouny Tarex et al. Prospective complex at V1, V2 or after V1, V2 lead. validation of A sezer ECG algorithm for The result of Muhammad’s study (2008) localization of accrssory pathways in patients was: Se of 97% and Sp of 95% [10]. For with Wolff-Parkinson-White syndrome. AAMJ. the anterior or posterior accessory 2012, 10, Suppl-2. pathways by positive/negative Delta 3. Noriko Taguchi, Yasuya Inden et al. A waves in inferior, Muhammad showed simple algorithm for localizing accessory that Se and Sp from 85 - 100% [10]. pathways in patients with Wolff-Parkinson- White syndrome using only the R/S ratio. CONCLUSION Journal of Arrhythmia. 2013. We have developed a new algorithm in 4. Andre D’avila, Vassilis Skeberis et al. A localizing accessory pathway and fast and reliable algorithm to localize accessory pathways based on the polarity of validated it. We found that the left side the QRS complex on the surface ECG during had Delta wave positive was most sinus rhythm. Pace. 1995, 18. common at V1 lead (97.2%) and right side 5. Fananapazir L, Gallagher J.J, Lowe J.E, had Delta wave negative that was most Prystowsky E.N. Importance of preexcited common at V1 lead (83.8%). Classified QRS morphology during induced atrial transition of septal location was most fibrillation to the diagnosis and localization of common at V1, V2 lead (89.2%) while multiple accessory pathways. Circulation. classified transition of lateral free wall 1990, 81, pp.578-85. 63
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