A New Electrocardiographic Criterium to Estimate a Septal or Lateral Location of a Right-Sided Accessory Pathway

José Nunes De Alencar Neto,Claudio Cirenza,Angelo Amato Vincenzo De Paola,Rogério Gomes De Almeida Neto

doi:10.24207/jca.v33i1.3387

José Nunes De Alencar Neto, Claudio Cirenza + Show 2 more

Open Access

https://doi.org/10.24207/jca.v33i1.3387

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Abstract

Introduction: There are algorithms to estimate the location of an accessory pathway (AP). However, in right-sided APs, they tend to present low accuracy. This paper presents a new electrocardiographic criterium to estimate the location of a right-sided AP. Materials and methods: Rest ECGs from patients with manifest pre-excitation of right-sided APs were evaluated and the SV2/RV3 ratio was calculated, considering values <1 for lateral (anterior or posterior) and ≥ 1 for septal (anterior or posterior) APs. We compared this ratio with other signs already described in literature. Results: In 175 consecutive patients, 60 met the inclusion criteria. For APs located in superior portions of tricuspid ring, the SV2/RV3 ratio <1 was 80% accurate for anteroseptal location (specificity: 75%), where His electrograms were recorded. For APs located in inferior portions of tricuspid ring A SV2/RV3 < 1 was 82,86% accurate for mid and posteroseptal location (specificity: 95.38%). Conclusion: We report a new and simple criterium that can accurately distinguish right-sided lateral and septal APs with good specificity: SV2/RV3 ratio.

Highlights

In the general population, the prevalence of Wolff–Parkinson–White syndrome (WPW) is estimated to be 1–3 per 1000 individuals[1,2,3]
The syndrome is defined as the association of a short PR interval, a delta wave, and the occurrence of atrioventricular reentrant tachycardias (AVRTs) with retrograde conduction or anterograde by the nondecremental rapid conduction accessory pathway (AP)[4,5]
The electrocardiographic analysis of the characteristics of the ventricular preexcitation is crucial because it guides the electrophysiologists to affirm if this accessory pathway is located in the tricuspid or mitral ring, if it is located next to some noble structure for the cardiac conduction system, more superiorly or more inferiorly, etc

Summary

Introduction

The prevalence of Wolff–Parkinson–White syndrome (WPW) is estimated to be 1–3 per 1000 individuals[1,2,3]. Ablation of the accessory pathways is the treatment of choice in cases of APs with symptomatic and recurrent occurrences of AVRT or when there is high risk. The electrocardiographic analysis of the characteristics of the ventricular preexcitation is crucial because it guides the electrophysiologists to affirm if this accessory pathway is located in the tricuspid or mitral ring, if it is located next to some noble structure for the cardiac conduction system, more superiorly or more inferiorly, etc. The literature shows several algorithms and flow charts[6,7,8,9] Their accuracy for distinguishing mitral and tricuspid rings AP is high, and this allows electrophysiologists to plan a transseptal or retroaortic approach. A radiofrequency application in this area is accompanied by a risk of complete heart block

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