Discrimination of anterograde from retrograde atrial electrograms for physiologic pacing

The morphology of bipolar electrograms recorded in the right atrium was examined in nine patients in an attempt to discriminate retrograde from anterograde atrial signals to an extent that would be useful for physiologic pacing. Peak-to-peak amplitude, duration, square root of energy (energy), maximum slew rate, mean slew rate, and polarity were examined in the time domain. Maximum frequency, half-power frequency, Fourier amplitude peak, and frequency of peak were measured in the frequency domain. There was a significant difference between anterograde and retrograde signals for all variables related to amplitude; these variables are peak-to-peak amplitude, energy, Fourier amplitude peak, maximum slew rate and mean slew rate. In seven of nine patients there was at least one variable sufficiently discriminating to insure reliable detection of anterograde signals while systematically rejecting retrograde signals. However, no individual variable was able to effect this discrimination in more than four patients and at least three variables were needed for all seven patients: maximum frequency, one of either energy and Fourier amplitude peak, and one of either frequency of peak or half-power frequency (six possible combinations). Thus, although differences between anterograde and retrograde atrial activity can be demonstrated in most patients, no single parameter displays sufficient discriminating power to facilitate physiologic pacing in patients exhibiting retrograde activity.