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The P wave morphology in lead V7 on the synthesized 18-lead ECG is a useful parameter for identifying arrhythmias originating from the right inferior pulmonary vein

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Abstract

Atrial tachyarrhythmias often originate from the superior vena cava (SVC), and right superior (RSPV) and inferior pulmonary veins (RIPV). However, a precise differentiation of those origins is challenging using the standard 12-lead electrocardiogram (ECG) P-wave morphology due to the anatomical proximity. The recently developed synthesized 18-lead ECG provides virtual waveforms of the right-sided chest and back leads. This study evaluated the utility of the synthesized 18-lead ECG to differentiate atrial arrhythmias originating from 3 adjacent structures. Synthesized 18-lead ECGs were obtained during SVC-, RSPV-, and RIPV-pacing in 20 patients with lone paroxysmal atrial fibrillation to develop an algorithm. The P-wave morphologies were classified into 4 patterns: positive, negative, biphasic, and isoelectric. Subsequently, the algorithm’s accuracy was validated prospectively in another 40 patients. In retrospective analyses, isoelectric P-waves in synthesized V7 distinguished RIPV-pacing from the others (sensitivity = 81%, specificity = 92%) (first criteria). The P wave morphologies in Leads II (sensitivity = 83%, specificity = 94%) and V1 (sensitivity = 84%, specificity = 80%) distinguished SVC- and RSPV-pacing (second criteria). In a prospective evaluation, the sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], and accuracy of the first criteria for identifying RIPV-pacing was 97%, 90%, 78%, 99%, and 92%, respectively. The sensitivity, specificity, RPV, NPV, and accuracy of the second criteria (amplitudes > 1 mV in lead II or biphasic P-waves in lead V1) for discriminating SVC- and RSPV-pacing was 66%, 95%, 98%, 50%, and 74%, respectively. The P wave morphology pattern in lead V7 in synthesized 18-lead ECGs is useful for differentiating RIPV origins from RSPV/SVC origins.

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Acknowledgements

We thank Mr. John Martin for his help in the preparation of the manuscript.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, 910-1193, Fukui, Japan

    Kaori Hisazaki, Shinsuke Miyazaki, Kanae Hasegawa, Kenichi Kaseno, Naoki Amaya, Yuichiro Shiomi, Naoto Tama, Hiroyuki Ikeda, Yoshitomo Fukuoka, Tetsuji Morishita, Kentaro Ishida, Hiroyasu Uzui & Hiroshi Tada

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  1. Kaori Hisazaki
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  2. Shinsuke Miyazaki
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  3. Kanae Hasegawa
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  4. Kenichi Kaseno
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  5. Naoki Amaya
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  6. Yuichiro Shiomi
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  8. Hiroyuki Ikeda
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  12. Hiroyasu Uzui
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  13. Hiroshi Tada
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Correspondence to Shinsuke Miyazaki.

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Hisazaki, K., Miyazaki, S., Hasegawa, K. et al. The P wave morphology in lead V7 on the synthesized 18-lead ECG is a useful parameter for identifying arrhythmias originating from the right inferior pulmonary vein. Heart Vessels 35, 246–251 (2020). https://doi.org/10.1007/s00380-019-01483-1

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  • DOI: https://doi.org/10.1007/s00380-019-01483-1

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