Diagnostic Accuracy of 12-Lead ECG Algorithms for Accessory Pathway Localization in WPW: A Meta-Analysis

In Wolff-Parkinson-White (WPW) syndrome, accurate localization of accessory pathways before catheter ablation can improve procedural planning and efficiency. Several 12-lead electrocardiographic (ECG) algorithms have been proposed, but their diagnostic performance has not been consistently established. We performed a systematic review and meta-analysis to assess the accuracy of ECG-based algorithms for accessory pathway localization in manifest WPW.

Following PRISMA-DTA recommendations, PubMed, EMBASE, Cochrane CENTRAL, Web of Science, and Scopus were searched from January 1990 to January 2026. Studies enrolling adult or pediatric patients with manifest pre-excitation who underwent electrophysiological study (EPS) and catheter ablation were included. Successful localization during EPS/ablation served as the reference standard. Random-effects models were used to calculate pooled diagnostic accuracy, sensitivity, specificity, and diagnostic odds ratios (DOR). Summary receiver operating characteristic and leave-one-out sensitivity analyses were also performed.

Seventeen studies involving 3159 patients met inclusion criteria. The pooled diagnostic accuracy of ECG algorithms was 0.91 (95% CI 0.85-0.94), although heterogeneity was substantial (I² = 91.4%). Pooled sensitivity was 0.87 (95% CI 0.73-0.94), and pooled specificity was 0.98 (95% CI 0.95-0.99; I² = 0%). The pooled DOR was 297.17 (95% CI 46.33-1906.19; p<0.0001). Sensitivity analyses showed stable results after sequential exclusion of individual studies.

Twelve-lead ECG algorithms provide high diagnostic performance for accessory pathway localization in manifest WPW and may be useful adjuncts for pre-ablation planning, although invasive electrophysiological mapping remains essential.