ECG criteria for localizing the pulmonary vein origin of spontaneous atrial premature complexes: Validation using intracardiac recordings

We have shown that pacemapping from each of the pulmonary veins reveals unique surface ECG characteristics. However, application of these criteria to spontaneous atrial premature complexes is often difficult because of obscuration by the prior T wave. We hypothesized that the pulmonary vein of origin of spontaneous atria] premature complexes can be determined by measuring characteristics of the P wave whether or not the P wave was superimposed on the prior T wave. We analyzed 58 spontaneous atrial premature complexes of known pulmonary vein origin in 30 patients referred for atria] fibrillation ablation. The origin of all the atria] premature complexes was documented by detailed, intracardiac multipolar catheter mapping. Based on previous work, the criteria for distinguishing right-sided from left-sided pulmonary vein origin of atria] premature complex includes: (1) P wave duration < 120 ms; (2) P wave amplitude in lead I > 0.05 mV; and (3) P wave amplitude in leads II/III > 1.25. The criteria to separate superior from inferior pulmonary veins included the sum of the P wave amplitude in all the inferior leads greater than 0.3 mV The combination of the P wave duration < 120 ms and the ratio of the P wave amplitude in leads II/III > 1.25, distinguished right-sided from left-sided pulmonary vein origin of spontaneous atria] premature complexes with a sensitivity of 82% and specificity of 100%. The sum of the P wave amplitude in leads II, III, and aVF > 0.3 mV distinguished superior from inferior pulmonary vein of origin with a sensitivity of 39% and specificity of 73%. The pulmonary vein origin of spontaneous atrial premature complexes can often be localized using careful quantitative analysis of the surface ECG despite superimposition of the P wave upon the T wave. Separation of right-sided from left-sided pulmonary vein origin of spontaneous atrial premature complexes can be determined with good specificity and sensitivity, while the ability to distinguish inferior from superior pulmonary vein origin is limited.