Localizing the Accessory Pathway in Ventricular Preexcitation Patients Using a Score Based Algorithm

L. J. Rantner; M. C. Stühlinger; C. N. Nowak; K. Spuller; K. Etsadashvili; X. Stühlinger; T. Berger; W. Dichtl; R. M. Gothe; G. Fischer; F. Hintringer

doi:10.3414/ME11-01-0046

Methods of Information in Medicine, Table of Contents

Methods Inf Med 2012; 51(01): 3-12
DOI: 10.3414/ME11-01-0046

Original Articles

Schattauer GmbH

Localizing the Accessory Pathway in Ventricular Preexcitation Patients Using a Score Based Algorithm

L. J. Rantner

¹Institute of Electrical, Electronic and Bioengineering, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall in Tirol, Austria

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

⁴Current address: Department of Biomedical Engineering and Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA

,

M. C. Stühlinger

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

,

C. N. Nowak

¹Institute of Electrical, Electronic and Bioengineering, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall in Tirol, Austria

,

K. Spuller

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

,

K. Etsadashvili

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

,

X. Stühlinger

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

,

T. Berger

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

,

W. Dichtl

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

,

R. M. Gothe

³Department of Public Health and Health Technology Assessment, UMIT, Hall in Tirol, Austria

,

G. Fischer

¹Institute of Electrical, Electronic and Bioengineering, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall in Tirol, Austria

,

F. Hintringer

²Division of Cardiology, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria

› Author Affiliations

Abstract

Summary

Objectives: Clinical data was analyzed to find an efficient way to localize the accessory pathway in patients with ventricular preexcitation.

Methods: The delta wave morphologies and ablation sites of 186 patients who underwent catheter ablation were analyzed and an algorithm (“locAP”) to localize the accessory pathway was developed from the 84 data sets with a PQ interval ≤ 0.12 s and a QRS width ≥ 0.12 s. Fifty additional patients were included for a prospective validation. The locAP algorithm ranks 13 locations according to the likelihood that the accessory pathway is localized there. The algorithm is based on the locAP score which uses the standardized residuals of the available data sets.

Results: The locAP algorithm’s accuracy is 0.54 for 13 locations, with a sensitivity of 0.84, a specificity of 0.97, and a positive likelihood ratio of 24.94. If the two most likely locations are regarded, the accuracy rises to 0.79, for the three most likely locations combined the accuracy is 0.82. This new algorithm performs better than Milstein’s, Fitzpatrick’s, and Arruda’s algorithm both in the original study population as well as in a prospective study.

Conclusions: The locAP algorithm is a valid and valuable tool for clinical practice in a cardiac electrophysiology laboratory. It could be shown that use of the locAP algorithm is favorable over the localizing algorithms that are in clinical use today.

Keywords

Accessory pathway - algorithms - delta wave - electrocardiography - Wolff-Parkinson-White syndrome

Full Text

References

References
1 Olgin JE, Zipes DP. Braunwald’s heart disease: a textbook of cardiovascular medicine. In. 2004
2 Yee R, Klein GJ, Prystowsky E. Cardiac electrophysiology: from cell to bedside. In. 2000
3 Jackman WM, Wang XZ, Friday KJ, Roman CA, Moulton KP, Beckman KJ. et al Catheter ablation of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome) by radiofrequency current. N Engl J Med 1991; 324: 1605-1611.
4 Morady F. Radio-frequency ablation as treatment for cardiac arrhythmias. N Engl J Med 1999; 340: 534-544.
5 Rosner MH, Brady Jr WJ, Kefer MP, Martin ML. Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues. Am J Emerg Med 1999; 17: 705-714.
6 Blomström-Lundqvist C, Scheinman M, Aliot E, Alpert J, Calkins H, Camm A. et al ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias - executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation 2003; 108: 1871-1909.
7 Fuster V, Ryden L, Cannom D, Crijns H, Curtis A, Ellenbogen K. et al ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114: e257-354.
8 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M. et al ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114: e385-484.
9 Willems JL, Robles de Medina EO, Bernard R, Coumel P, Fisch C, Krikler D. et al Criteria for intraventricular conduction disturbances and pre-excitation. World Health Organizational/International Society and Federation for Cardiology Task Force Ad Hoc. J Am Coll Cardiol 1985; 5: 1261-1275.
10 Arruda MS, McClelland JH, Wang X, Beckman KJ, Widman LE, Gonzalez MD. et al Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol 1998; 9: 2-12.
11 Fitzpatrick AP, Gonzales RP, Lesh MD, Modin GW, Lee RJ, Scheinman MM. New algorithm for the localization of accessory atrioventricular connections using a baseline electrocardiogram. J Am Coll Cardiol 1994; 23: 107-116.
12 Milstein S, Sharma AD, Guiraudon GM, Klein GJ. An algorithm for the electrocardiographic localization of accessory pathways in the Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol 1987; 10: 555-563.
13 Skeberis V, Tsakonas K, Simonis F, Steurer G, Celiker A, Andries E. et al A fast and reliable method to localize accessory pathways on the electrocardiogram during sinus rhythm. Circulation 1992; 86: I-129.
14 Xie B, Heald SC, Bashir Y, Katritsis D, Murgatroyd FD, Camm AJ. et al Localization of accessory pathways from the 12-lead electrocardiogram using a new algorithm. Am J Cardiol 1994; 74: 161-165.
15 Cosio FG, Anderson RH, Kuck KH, Becker A, Borggrefe M, Campbell RW. et al Living anatomy of the atrioventricular junctions. A guide to electrophysiologic mapping. A Consensus Statement from the Cardiac Nomenclature Study Group, Working Group of Arrhythmias, European Society of Cardiology, and the Task Force on Cardiac Nomenclature from NASPE. Circulation 1999; 100: e31-37.
16 Altman DG. Practical statistics for medical research. Chapman & Hall/CRC 1990
17 Bossuyt P, Reitsma J, Bruns D, Gatsonis C, Glasziou P, Irwig L. et al The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 2003; 138: W1-12.
18 Bossuyt P, Reitsma J. Standards for Reporting of Diagnostic Accuracy. The STARD initiative. Lancet 2003 361 71
19 Katsouras CS, Greakas GF, Goudevenos JA, Michalis LK, Kolettis T, Economides C. et al Localization of accessory pathways by the electrocardiogram: which is the degree of accordance of three algorithms in use?. Pacing Clin Electrophysiol 2004; 27: 189-193.
20 Boersma L, Garcia-Moran E, Mont L, Brugada J. Accessory pathway localization by QRS polarity in children with Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol 2002; 13: 1222-1226.
21 Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994; 271: 703-707.
22 Jaeschke R, Guyatt G, Sackett DL. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1994; 271: 389-391.
23 Fischer G, Hanser F, Pfeifer B, Seger M, Hintermüller C, Modre R. et al A signal processing pipeline for noninvasive imaging of ventricular preexcitation. Methods Inf Med 2005; 44: 508-515.
24 Berger T, Fischer G, Pfeifer B, Modre R, Hanser F, Trieb T. et al Single-beat noninvasive imaging of cardiac electrophysiology of ventricular pre-excitation. J Am Coll Cardiol 2006; 48: 2045-2052.
25 Pfeifer B, Seger M, Hintermüller C, Fischer G, Mühlthaler H, Modre-Osprian R. et al AAM-based segmentation for imaging cardiac electrophysiology. Methods Inf Med 2007; 46: 36-42.
26 Standards Committee of the IEEE Computer Society, USA. IEEE standard for binary floating-point arithmetic; 1985. IEEE Std 754-1985. Available from http://ieeexplore.ieee.org/servlet/opac?punumber=2355.