title: Testing of a new T-wave subtraction algorithm as an aid to localizing ectopic atrial beats.
abstract: BACKGROUND
  Identifying the timing and morphology of an ectopic P wave from the surface electrogram can aid in the diagnosis and localization of atrial arrhythmias. Given the relatively short coupling interval of atrial ectopic beats, the P wave is often obscured by the larger amplitude QRS-T wave complex. A method to uncover such "buried" P waves using a standard 12-lead surface ECG would be clinically useful and could potentially be a noninvasive guide to catheter ablation of focal atrial tachycardia.
  
  
  METHODS
  We developed an automated computerized program (BARD DUO LAB SYSTEM trade mark ) designed to subtract the QRS-T wave complex from the surface electrogram and uncover a previously obscured P wave. The purpose of the present study was to validate this program. The surface ECG from 21 patients undergoing atrial pacing during electrophysiologic study (group I) and 10 patients with atrial tachycardia (group II) were analyzed and the derived P-wave morphology assessed using correlation waveform analysis (CWA) and visual grading by three reviewers.
  
  
  RESULTS
  The algorithm successfully uncovered the P wave in each surface ECG. For the 21 patients in group I, average CWA comparing the derived P wave with the previous paced P wave was 83%. Average CWA for group II was 82%. Visual grading of the match between derived P waves and paced P waves revealed a 21/21 match in group I patients and a 12/12 match in 9/10 of group II patients.
  
  
  CONCLUSIONS
  An ectopic atrial P wave obscured by a coincident QRS-T wave complex can be accurately uncovered using this new algorithm. Addition of this technique to existing methods may improve the diagnosis of atrial arrhythmias and aid in the localization and ablation of ectopic atrial foci.
authors.affiliation: Tufts University School of Medicine, New England Medical Center Hospitals, Boston, MA 02111, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Marenco
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Nakagawa
authors.forename: Shawn
authors.initials: S
authors.lastname: Yang
authors.forename: David
authors.initials: D
authors.lastname: MacAdam
authors.forename: Lucien
authors.initials: L
authors.lastname: Xu
authors.forename: Ding S
authors.initials: DS
authors.lastname: He
authors.forename: Mark S
authors.initials: MS
authors.lastname: Link
authors.forename: Munther K
authors.initials: MK
authors.lastname: Homoud
authors.forename: N A Mark
authors.initials: NA
authors.lastname: Estes III
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Wang
mesh_terms: D000465:Algorithms; D018880:Atrial Premature Complexes / Q000175:diagnosis* / Q000503:physiopathology; D004562:Electrocardiography / Q000379:methods*; D006801:Humans; D007090:Image Interpretation, Computer-Assisted