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

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.