Maximal Pre-Excitation Based Algorithm for Localization of Manifest Accessory Pathways in Adults

JACC Clin Electrophysiol. 2018 Aug;4(8):1052-1061. doi: 10.1016/j.jacep.2018.03.018. Epub 2018 May 30.


Objectives: This study evaluated a new algorithm relying on maximal pre-excitation.

Background: Prior knowledge of accessory pathway (AP) location facilitates an individual ablation strategy. Delta-wave analysis on a 12-lead electrocardiogram is recognized as crucial for predicting ablation site, but can be ambiguous at basal state.

Methods: An algorithm based on maximal pre-excitation, as induced by atrial pacing during an electrophysiological study, was initially developed in 132 patients with a single manifest AP. The maximally pre-excited QRS features included the global polarity in lead V1 (step 1), inferior leads (step 2), and leads V3 or I (step 3), as well as the morphology in lead II (step 4). Three investigators prospectively tested the new algorithm in 207 consecutive patients by comparing its efficacy to a control algorithm relying on basal pre-excitation.

Results: The accuracy, defined as the percent of patients with an exact prediction of AP location, was significantly greater with the new algorithm (90% vs. 63%; p < 0.001). The reproducibility, defined as the level of agreement between investigators in determining AP location, was excellent (κ > 0.75; p < 0.05) with the new algorithm and fair (0.40 < κ < 0.75; p < 0.05) with the control algorithm.

Conclusions: An algorithm based on maximal pre-excitation allows accurate and reproducible localization of manifest APs. When ablation is indicated, the analysis of maximal pre-excitation is a sensible approach for giving a head start in endocardial mapping.

Keywords: accessory pathway; algorithm; catheter ablation; maximal pre-excitation.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Accessory Atrioventricular Bundle* / diagnosis
  • Accessory Atrioventricular Bundle* / physiopathology
  • Adult
  • Algorithms*
  • Catheter Ablation / methods*
  • Cohort Studies
  • Electrocardiography / methods*
  • Humans
  • Signal Processing, Computer-Assisted*