Simultaneous atrial and ventricular pacing to facilitate mapping of concealed left-sided accessory pathways

Several local electrogram characteristics have been proposed as criteria to predict successful ablation. However, poor specificity due to obscuration of the retrograde atrial electrogram by the ventricular electrogram is problematic. The aim of this study was to analyze local electrograms obtained by simultaneous pacing to identify quantitative criteria that may predict successful ablation sites for concealed left free-wall accessory pathways. Twenty-four local electrograms from 10 successful and 14 unsuccessful ablation sites in ten patients were analyzed. Retrograde atrial electrograms were confirmed by the simultaneous pacing method. The intervals between the retrograde atrial electrogram of the coronary sinus and the ablation site, the initiation of the ventricular electrogram and the retrograde atrial electrogram, and the stimulus and retrograde atrial electrogram were analyzed. All retrograde atrial electrograms could be confirmed clearly by the simultaneous pacing method. The interval between the retrograde atrial electrogram of the coronary sinus and that of the ablation site was shorter at successful sites than at unsuccessful sites (-7.0 +/- 9.2 ms vs 5.7 +/- 2.7 ms; 95% confidence interval, -18 to -7; P < 0.0001). An interval of < or = 0 ms resulted in 100% sensitivity and 92.7% specificity for success. The other two interval measurements at successful sites did not differ significantly from those at unsuccessful sites. The authors propose an interval of < or = 0 ms between the retrograde atrial electrogram of the coronary sinus and that of the ablation site confirmed by the simultaneous pacing method as a quantitative criterion to identify the successful ablation site for concealed left free-wall accessory pathways. Application of this criterion may reduce the number of unnecessary ablations.