Morphological characteristics of P waves during selective pulmonary vein pacing

OBJECTIVES We sought to assess the value of 12-lead electrocardiogram (ECG) P-wave morphology to recognize the paced pulmonary vein (PV). BACKGROUND Prediction of arrhythmogenic PVs producing ectopy or initiating atrial fibrillation (AF) using 12-lead ECG may facilitate curative ablation. METHODS In 30 patients P-wave configurations were studied during sinus rhythm and during pacing at six sites from the four PVs: top and bottom of each superior PV and both inferior PVs. The P-wave amplitude, duration and morphology were assessed, and predictive accuracies were calculated for the most significant parameters. An algorithm predicting the paced PV was developed and prospectively evaluated in a different population of 20 patients. RESULTS Three criteria were used to distinguish right from left PV: 1) a positive P-wave in lead aVL and the amplitude of P-wave in lead I ≥50 μV indicated right PV origin (specificity 100% and 97%, respectively); 2) a notched P-wave in lead II was a predictor of left PV origin (specificity 95%); and 3) the amplitude ratio of lead III/II and the duration of positivity in lead V1 were also helpful in distinguishing left versus right PV origin. In addition, superior PVs could be distinguished from inferior according to the amplitude in lead II (≥100 μV). In prospective evaluation, an algorithm based on the above four criteria identified 93% of left versus right PV and totally 79% of the specific PVs paced. CONCLUSIONS Pacing from the different PVs produced a P-wave with distinctive characteristics that could be used as criteria in an algorithm to identify the PV of origin with an accuracy of 79%.