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

Background 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. Methods 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. Results 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 (I 2 = 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; I 2 = 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. Conclusion 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.