P-wave morphology in focal atrial tachycardia - Development of an algorithm to predict the anatomic site of origin

OBJECTIVES The purpose of this study was to perform a detailed analysis of the P-wave morphology (PWM) in focal atrial tachycardia (AT) and construct and prospectively evaluate an algorithm for identification of the anatomic site of origin. BACKGROUND Although smaller studies have described the PWM from particular anatomic locations, a detailed algorithm characterizing the likely location of a tachycardia associated with a P-wave of unknown origin has been lacking. METHODS The PWMs for 126 consecutive patients undergoing successfid radiofrequency ablation of 130 ATs are reported. P waves were included only when the onset was preceded by a discernible isoelectric segment. P waves were classified as positive (+), negative (-), isoelectric, or biphasic. Sensitivity, specificity, and predictive values were calculated. On the basis of these results, an algorithm was constructed and prospectively evaluated in 30 new consecutive ATs. RESULTS The distribution of ATs was right atrial (RA) in 82 of 130 (63%) and left atrial (LA) in 48 of 130 (37%). Right atrial sites included crista (n = 28), tricuspid annulus (n = 29), coronary sinus (CS) ostium (n = 14), perinodal (n = 7), right septum (n = 1), and RA appendage (n = 3). Left atrial sites included pulmonary veins (n = 32), mitral annulus (n = 8), CS body (n = 3), left septum (n = 3), and LA appendage (n = 2). In electrocardiographic lead V,, a negative or +/- P-wave demonstrated a specificity of 100% for a RA focus, and a + or -/+ P-wave demonstrated a sensitivity of 100% for a LA focus. A characteristic PWM was associated with high sensitivity and specificity at common atrial sites for tachycardia foci. A P-wave algorithm correctly identified the focus in 93%. CONCLUSIONS Characteristic PWMs corresponding to known anatomic sites for focal AT are associated with high specificity and sensitivity. A P-wave algorithm correctly identified the site of tachycardia origin in 93%.