Diagnostic Accuracy of 12-Lead Electrocardiographic Algorithms in Predicting the Origin of Idiopathic Premature Ventricular Complexes: Comparison with Ablation Outcomes

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Idiopathic premature ventricular complexes (PVCs) (n=32). Intervention: Yamada 12-lead ECG localization algorithm (and V2S/V3R index) vs. Enriquez 4-step ECG algorithm (and V2 transition ratio / R-wave duration index) against electrophysiologically confirmed ablation site. Primary outcome: Exact regional concordance with the electrophysiologically confirmed successful ablation site (p=0.0004).

Q: What does this research mean for the field?

The Yamada 12-lead ECG algorithm achieves significantly higher exact regional concordance than the Enriquez algorithm in localizing idiopathic PVC origins, while the V2S/V3R index provides the highest accuracy for outflow tract differentiation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Selim Ekinci; Hakan Gökalp Uzun

doi:10.4274/imj.galenos.2026.45894

October 30, 2026Istanbul Medical JournalOpen Access

Diagnostic Accuracy of 12-Lead Electrocardiographic Algorithms in Predicting the Origin of Idiopathic Premature Ventricular Complexes: Comparison with Ablation Outcomes

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Key result

Yamada ECG algorithm achieves ~50-point higher regional concordance than Enriquez for idiopathic PVCs.

P=0.0004
n=32

Why the study?

Accurate preprocedural localization of idiopathic premature ventricular complexes using 12-lead ECG may facilitate catheter ablation planning, but the diagnostic performance of ECG criteria and localization algorithms remains variable.

What is the diagnostic accuracy of five 12-lead ECG algorithms (V2S/V3R index, V2 transition ratio, RwDI, Enriquez algorithm, and Yamada algorithm) in predicting the successful catheter ablation site in patients with idiopathic premature ventricular complexes?

Key Points

To evaluate the diagnostic accuracy of five 12-lead electrocardiographic criteria and localization algorithms in predicting the successful catheter ablation site of idiopathic premature ventricular complexes.
Single-center retrospective diagnostic accuracy study of 32 patients undergoing successful catheter ablation for symptomatic idiopathic premature ventricular complexes, using the electrophysiologically confirmed successful ablation site as the reference standard.
Analyzed intraprocedural 12-lead ECG recordings using three outflow tract binary tools (V2S/V3R index, V2 transition ratio, R-wave duration index) and two regional localization algorithms (Yamada and Enriquez).
For outflow tract discrimination, the V2S/V3R index achieved the highest accuracy at 80.8% (sensitivity 85.7%, specificity 75.0%), compared with 61.9% for the V2 transition ratio and 72.2% for the R-wave duration index (sensitivity 16.7%, specificity 100.0%).
For comprehensive localization, the Yamada algorithm demonstrated significantly higher exact regional concordance than the Enriquez algorithm (81.3% vs. 31.3%, p=0.0004) and higher lateralization accuracy (87.5% vs. 56.3%).
Catheter ablation achieved acute procedural success in all 32 patients without major procedural complications, and arrhythmia recurrence occurred in 10 of 30 evaluable patients (33.3%) during follow-up.

Study Design

Type

Observational (n=32)

Blinding

Blinded outcome assessment (two reviewers blinded to ablation site and outcome)

Multicenter

No

Structured PICO

What is the diagnostic accuracy of five 12-lead ECG algorithms (V2S/V3R index, V2 transition ratio, RwDI, Enriquez algorithm, and Yamada algorithm) in predicting the successful catheter ablation site in patients with idiopathic premature ventricular complexes?

P

Population

32 adult patients (median age 54 years, 40.6% female) undergoing successful catheter ablation for idiopathic premature ventricular complexes without structural heart disease at a single center in Turkey.

E

Exposure

Preprocedural/intraprocedural 12-lead surface electrocardiogram (ECG) localization indices and algorithms: V2S/V3R index (ratio of S-wave amplitude in lead V2 to R-wave amplitude in lead V3), V2 transition ratio, R-wave duration index (RwDI), the 4-step regional localization algorithm by Enriquez et al., and the comprehensive regional localization algorithm by Yamada et al.

C

Comparator

Electrophysiologically confirmed successful catheter ablation site (reference standard), mapped using the EnSite X EP System and TactiCath Contact Force Ablation Catheter, with acute procedural success defined as abolition of the targeted PVC with no spontaneous or inducible recurrence during a 30-minute observation period.

O

Outcome

Diagnostic accuracy (overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value) and exact regional concordance in predicting the electrophysiologically confirmed successful ablation site.surrogate

Main Result

Absolute Event Rate: 81.3% vs 31.3%

p-value: p=0.0004

Limitations

Single-center retrospective design
Small overall sample size (n=32) and smaller morphological subgroups (as few as 14 patients), resulting in wide 95% confidence intervals
Absence of external validation in an independent, multicenter cohort
Only five ECG algorithms were assessed
Follow-up and recurrence assessment were based on retrospective clinical records rather than a prespecified prospective protocol
Single-center retrospective study design
Small overall sample size (n=32) and small overlapping applicable subsets (n=14-21), resulting in markedly underpowered pairwise McNemar tests
Two patients were lost to follow-up for recurrence assessment
Findings are hypothesis-generating and warrant external validation in larger, multicenter cohorts

Implication

In patients undergoing catheter ablation for idiopathic PVCs, the V2S/V3R index demonstrated the highest accuracy (80.8%) for outflow tract discrimination, while the Yamada algorithm provided superior whole-heart exact regional concordance (81.3%) compared to the Enriquez algorithm (31.3%).

Abstract

Introduction: Accurate preprocedural localization of the origin of idiopathic premature ventricular complexes (PVCs) using the 12lead electrocardiogram (ECG) may facilitate procedural planning for catheter ablation.However, the diagnostic performance of ECG criteria and localization algorithms remains variable.We aimed to evaluate the diagnostic accuracy of five ECG-based criteria or algorithms in predicting the successful ablation site in idiopathic PVCs.Methods: This study included 32 patients who underwent successful catheter ablation for idiopathic PVCs.The successful ablation site served as the reference standard.Intraprocedural ECG recordings were analyzed to calculate the ratio of S-wave amplitude in lead V2 to R-wave amplitude in lead V3 (V2S/V3R) index, V2 transition ratio, and R-wave duration index (RwDI) and to apply two previously published regional localization algorithms.For binary algorithms, diagnostic performance metrics were calculated; for regional algorithms, exact regional concordance was assessed.Results: Among the outflow tract discrimination tools, the V2S/V3R Index showed the best performance, with 80.8% accuracy, 85.7% sensitivity, and 75.0%specificity.The V2 Transition Ratio showed modest performance, whereas the RwDI had low sensitivity (16.7%) but perfect specificity (100.0%) for identifying aortic cusp origins.For comprehensive localization, the Yamada algorithm achieved 87.5% accuracy for left-vs.-rightventricular outflow tract (LVOT-RVOT) lateralization and 81.3% exact regional concordance, while the Enriquez algorithm achieved 56.3% accuracy and 31.3%exact regional concordance, respectively.Exact regional performance was significantly better with Yamada (p=0.0004).Conclusion: ECG algorithms showed variable performance for predicting the successful ablation site.The V2S/V3R index was the most useful for discriminating RVOT from LVOT, whereas the Yamada algorithm showed the best overall performance for whole-heart localization.These hypothesis-generating findings warrant external validation in larger, multicenter cohorts before clinical adoption.

Discussion

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Cite This Study

Ekinci et al. (2026) conducted an observational in Idiopathic premature ventricular complexes (PVCs) (n=32). Yamada 12-lead ECG localization algorithm (and V2S/V3R index) vs. Enriquez 4-step ECG algorithm (and V2 transition ratio / R-wave duration index) against electrophysiologically confirmed ablation site was evaluated on Exact regional concordance with the electrophysiologically confirmed successful ablation site (p=0.0004). The Yamada 12-lead ECG algorithm achieved 81.3% exact regional concordance in localizing idiopathic PVCs compared to 31.3% with the Enriquez algorithm (p=0.0004), while V2S/V3R had 80.8% accuracy.

synapsesocial.com/papers/6ae682bde432e7a5c4ef3736 https://doi.org/10.4274/imj.galenos.2026.45894

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Diagnostic Accuracy of 12-Lead Electrocardiographic Algorithms in Predicting the Origin of Idiopathic Premature Ventricular Complexes: Comparison with Ablation Outcomes

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Diagnostic Accuracy of 12-Lead Electrocardiographic Algorithms in Predicting the Origin of Idiopathic Premature Ventricular Complexes: Comparison with Ablation Outcomes

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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