title: Identification of P waves after the Cox-maze procedure: significance of right precordial leads V3R through V6R.
abstract: BACKGROUND
  The maze circuit lengthens the period of atrial depolarization and may lead to small or absent P waves, which may not be readily apparent in a standard 12-lead electrocardiogram. In this prospective study, we investigate if the right precordial leads V3R through V6R can improve detection of P waves and identification of atrial electrical activity.
  
  
  METHODS
  Standard 12-lead electrocardiograms (with leads I through III, aVR, aVL, aVF, and V1 through V6) and right precordial electrocardiograms (V3R through V6R) were recorded in 30 consecutive patients during the first 5 postoperative days and 1, 3, 6, 12, and 24 months after combined Cox-maze III procedure and mitral valve surgery. The P wave identification as an indication of atrial electrical activity and atrial contraction was proved by transesophageal echocardiographic identification of atrial contractions.
  
  
  RESULTS
  Despite echocardiographically identifiable atrial contractions, the P waves were not visible on standard 12-lead electrocardiograms in 7 (23%) patients after 1 and 3 months, and in 4 patients after 6 months. In contrast, right precordial electrocardiograms showed P waves in all of these patients that were best seen in lead V4R. Twelve and 24 months postoperatively, only 2 patients had no visible P waves in the standard leads that were still present in the right precordial leads. However, if P waves were easily identifiable in standard 12-lead electrocardiograms (23 patients at 1 and 3 months after surgery), the right precordial leads showed P waves only in 15 patients.
  
  
  CONCLUSIONS
  Right precordial electrocardiogram with leads V3R through V6R is a helpful tool for visualizing P waves after the Cox-maze procedure. Standard 12-lead electrocardiogram should be combined with right precordial electrocardiogram in all patients after the Cox-maze procedure.
authors.affiliation: Deutsches Herzzentrum Berlin, Germany. pasic@dhzb.de
authors.forename: M
authors.initials: M
authors.lastname: Pasic
authors.forename: M
authors.initials: M
authors.lastname: Musci
authors.forename: B
authors.initials: B
authors.lastname: Edelmann
authors.forename: H
authors.initials: H
authors.lastname: Siniawski
authors.forename: P
authors.initials: P
authors.lastname: Bergs
authors.forename: R
authors.initials: R
authors.lastname: Hetzer
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology* / Q000601:surgery*; D006348:Cardiac Surgical Procedures; D004562:Electrocardiography; D004566:Electrodes; D006329:Heart Conduction System; D006801:Humans; D008943:Mitral Valve / Q000601:surgery; D011446:Prospective Studies