From the Section of Cardiac Electrophysiology, Department of Medicine and
the Cardiovascular Research Institute (A.S., M.D.L.), University of California
at San Francisco; the Department of Cardiology (H.A.P.P., E.O.R.de M.), Heart
Lung Institute, University Hospital and State University of Utrecht, the
Netherlands; the Department of Cardiology (E.R.J., N.M.van H.), Antonius
Hospital, Nieuwegein, the Netherlands; and the Laboratory of Medical Physics
(A.C.L.), Academic Medical Center, University of Amsterdam, the Netherlands.
Correspondence to Arne SippensGroenewegen, MD, Section of Cardiac Electrophysiology, Department of Medicine, University of California at San Francisco, 500 Parnassus Ave, MU-East 4S, Box 1354, San Francisco, CA 94143-1354. E-mail sippens{at}ep4.ucsf.edu
Background—The morphology and
polarity of the P wave on 12-lead ECG are of limited clinical value in
localizing ectopic atrial rhythms. It was the aim of this study to
assess the spatial resolution of body surface P-wave integral mapping
in identifying the site of origin of ectopic right atrial (RA) impulse
formation in patients without structural atrial disease.
Methods and Results—Sixty-two–lead ECG recordings were
obtained during RA pacing at 86 distinct endocardial sites in nine
patients with normal biatrial anatomy. After P-wave integral
maps were generated for each paced activation sequence, 17 groups with
nearly identical map features were visually selected, and a mean P-wave
integral map was computed for each group. Supportive statistical
analysis to corroborate qualitative group selection was
performed by assessment of (1) intragroup pattern uniformity by use of
jackknife correlation coefficient analysis of the integral maps
contained in each group and (2) intergroup pattern variability by use
of the calculation of cross correlations between the 17 mean integral
maps. The spatial resolution of paced P-wave body surface mapping in
the right atrium was obtained by estimating the area size of
endocardial segments with nearly identical P-wave integral maps by use
of a biplane fluoroscopic method to compute the three-dimensional
position of each pacing site. The latter approach yielded a mean
endocardial segment size of 3.5±2.9 cm2 (range, 0.79 to
10.75 cm2).
Conclusions—Use of the P-wave morphology on the 62-lead surface
ECG in patients with normal biatrial anatomy allows separation
of the origin of ectopic RA impulse formation into one of 17 different
endocardial segments with an approximated area size of 3.5
cm2. This database of paced P-wave integral maps provides a
versatile clinical tool to perform detailed noninvasive localization of
right-sided atrial tachycardia before radiofrequency
catheter ablation.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Body Surface Mapping During Pacing at Multiple Sites in the Human Atrium
P-Wave Morphology of Ectopic Right Atrial Activation
Key Words: mapping • morphogenesis • pacing
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