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Multicenter Study
. 2023 Feb 16;25(2):600-609.
doi: 10.1093/europace/euac216.

EASY-WPW: a novel ECG-algorithm for easy and reliable localization of manifest accessory pathways in children and adults

Mustapha El Hamriti  1 , Martin Braun  1 , Stephan Molatta  1   2 , Guram Imnadze  1 , Moneeb Khalaph  1 , Philipp Lucas  1 , Julia Kathinka Nolting  3 , Khuraman Isgandarova  1 , Vanessa Sciacca  1 , Thomas Fink  1 , Leonard Bergau  1   4 , Christian Sohns  1 , Kunihiko Kiuchi  5   6 , Makoto Nishimori  5 , Christian-Hendrik Heeger  7 , Martin Borlich  8 , Dong-In Shin  9 , Sonia Busch  10 , Denise Guckel  1 , Philipp Sommer  1
Affiliations
Multicenter Study

EASY-WPW: a novel ECG-algorithm for easy and reliable localization of manifest accessory pathways in children and adults

Mustapha El Hamriti et al. Europace. .

Abstract

Aims: Accessory pathway (AP) ablation is a standard procedure for the treatment of Wolff-Parkinson-White syndrome (WPW). Twelve-lead electrocardiogram (ECG)-based delta wave analysis is essential for predicting ablation sites. Previous algorithms have shown to be complex, time-consuming, and unprecise. We aimed to retrospectively develop and prospectively validate a new, simple ECG-based algorithm considering the patients' heart axis allowing for exact localization of APs in patients undergoing ablation for WPW.

Methods and results: Our multicentre study included 211 patients undergoing ablation of a single manifest AP due to WPW between 2013 and 2021. The algorithm was developed retrospectively and validated prospectively by comparing its efficacy to two established ones (Pambrun and Arruda). All patients (32 ± 19 years old, 47% female) underwent successful pathway ablation. Prediction of AP-localization was correct in 197 patients (93%) (sensitivity 92%, specificity 99%, PPV 96%, and NPV 99%). Our algorithm was particularly useful in correctly localizing antero-septal/-lateral (sensitivity and specificity 100%) and posteroseptal (sensitivity 98%, specificity 92%) AP in proximity to the tricuspid valve. The accuracy of EASY-WPW was superior compared to the Pambrun (93% vs. 84%, P = 0.003*) and the Arruda algorithm (94% vs. 75%, P < 0.001*). A subgroup analysis of children (n = 58, 12 ± 4 years old, 55% female) revealed superiority to the Arruda algorithm (P < 0.001*). The reproducibility of our algorithm was excellent (ϰ>0.8; P < 0.001*).

Conclusion: The novel EASY-WPW algorithm provides reliable and accurate pre-interventional ablation site determination in WPW patients. Only two steps are necessary to locate left-sided AP, and three steps to determine right-sided AP.

Keywords: Accessory pathway localization; Algorithm; Catheter ablation; Electrocardiography; Wolff-Parkinson-White syndrome.

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Conflict of interest statement

Conflict of interest: Philipp Sommer is member of the advisory board of Abbott, Biosense Webster, Boston Scientific and Medtronic. Christian Heeger is member of the advisory board of Biosense Webster. The other authors have nothing to declare.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Accessory pathway’s distribution. Schematic representation of the atrioventricular junction region as viewed in the left anterior oblique view (60°). Clockwise (bold numbers) the following accessory pathway localizations are distinguished: TV, tricuspid valve: AL, anterolateral; AS, anteroseptal; PL, posterolateral; PS, posteroseptal; MV, mitral valve: AL, PL, PS; HIS, His bundle.
Figure 2
Figure 2
Flowchart for stepwise AP-identification. The validated EASY-WPW algorithm with a three-step approach for right-sided AP (tricuspid valve) and a two-step approach for left-sided AP (mitral valve). AL, anterolateral; AP, accessory pathway; AS, anteroseptal; PL, posterolateral; PS, posteroseptal.
Figure 3
Figure 3
Left-sided accessory pathways. Schematic representation of the MV junction region as viewed in the left anterior oblique view (60°) illustrating posteroseptal (A), anterolateral (B), and posterolateral (C) AP-localizations. The adjacent Cabrera circles indicate the corresponding leads with the most positive delta wave (bold red arrow). ECG-Identification of a left-sided posterolateral AP with the EASY-WPW algorithm (D). MV, mitral valve; PS, posteroseptal; AL, anterolateral; PL, posterolateral; AP, accessory pathway.
Figure 4
Figure 4
Right-sided accessory pathways with QRS transition ≤ V3. Schematic representation of the TV junction region as viewed in the left anterior oblique view (60°) illustrating posteroseptal (A) and anteroseptal (B) AP-localization. The adjacent Cabrera circles indicate the corresponding leads with the most positive delta wave (bold arrow). ECG-identification of a right-sided posteroseptal AP with the EASY-WPW algorithm (C).TV, tricuspid valve; PS, posteroseptal; AS, anteroseptal; HIS, His bundle; AP, accessory pathway.
Figure 5
Figure 5
Right-sided accessory pathways with QRS transition > V3. Schematic representation of the TV junction region as viewed in the left anterior oblique view (60°) illustrating anterolateral (A), anteroseptal (B), posterolateral (C), and posteroseptal (D) AP-localization. The adjacent Cabrera circles indicate the corresponding leads with the most positive delta wave (bold arrow). ECG-identification of a right-sided anterolateral AP with the EASY-WPW algorithm (E). AL, anterolateral; AP, accessory pathway; AS, anteroseptal; HIS, His bundle; PS, posteroseptal; PL, posterolateral; TV, tricuspid valve.
Figure 6
Figure 6
Direct comparison of AP-algorithms. Direct comparison of the accuracy of AP-algorithms. In all patients, the accuracy (percentage of patients with an exact prediction of AP-localization) of the EASY-WPW algorithm was superior compared to the PAMBRUN (93% vs. 84%, P = 0.003*) and the ARRUDA algorithm (94% vs. 75%, P < 0.001*) (A). A subgroup analysis of children < 18 years old revealed significant superiority to the ARRUDA algorithm (P < 0.001*) (B). P < 0.05 and * indicate statistical significance. AP, accessory pathway.
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