Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle, Guided by Intracardiac Echocardiography and Image Integration

Abstract

T he papillary muscles (PMs) from the left ventricle (LV) have been shown to be a potential site of origin of ventricular arrhythmias (VAs) in patients with and without structural heart disease.1 Catheter ablation has been described as an effective treatment for these arrhythmias, although radiofrequency delivery at these regions has been associated with poor manipulation and catheter stability compared with other VAs. 2 See Editorial by Latchamsetty and BogunPrevious data on catheter cryoablation of PMs VAs showed high-success and low complication rates. 3 There is yet no data available comparing results of both cryoenergy and radiofrequency for catheter cryoablation of PM-related arrhythmias.This study compares procedural outcomes and recurrence rate after catheter cryoablation or radiofrequency ablation for the treatment of ventricular tachycardia (VT) and premature ventricular complexes (PVCs) localized at the PMs of the LV, with the aid of intracardiac echocardiography (ICE) and image integration. MethodsA total of 21 patients with recurrent VAs originating at the PMs of the LV were identified from retrospective review of 189 consecutive patients (men 52%, age 44 years, range 28-54 years) with symptomatic sustained VT (n=58), nonsustained VT (n=40), or PVC (n=91) referred for catheter ablation to the Buenos Aires Cardiovascular Institute (Buenos Aires, Argentina) between January 2014 and January 2016. Scar-related VT was observed in 45 patients (24%). The sites of origin of idiopathic VAs included the right ventricular (RV) outflow tract in 82 (43%), aortomitral continuity in 24 (13%), posteromedial PM (PMPM) in 19 (10%), anterolateral PM (ALPM) in 3 (1.5%), aortic root in 3 (1.5%), fascicles of the left bundle branch in 2 (1%), mitral annulus in 1 (0.5%), and other sites in 11 (6%). This study retrospectively included 21 patients with symptomatic, drug refractory, and single morphology VAs originated at the PMs of the LV. The institutional review committee approved the study and © 2016 American Heart Association, Inc. Circ Arrhythm Electrophysiol Original ArticleBackground-Catheter radiofrequency ablation of ventricular arrhythmias (VAs) arising from the left ventricle's papillary muscles has been associated with inconsistent results. The use of cryoenergy versus radiofrequency has not been compared yet. This study compares outcomes and complications of catheter ablation of VA from the papillary muscles of the left ventricle with either cryoenergy or radiofrequency. Methods and Results-Twenty-one patients (40±12 years old; 47% males; median ejection fraction 59±7.3%) with drug refractory premature ventricular contractions or ventricular tachycardia underwent catheter cryoablation or radiofrequency ablation. VAs were localized using 3-dimensional mapping, multidetector computed tomography, and intracardiac echocardiography, with arrhythmia foci being mapped at either the anterolateral papillary muscle or posteromedial papillary muscles of the left ventricle. Focal ablation was performed using an 8-mm cryoa...

Worsening of mitral valve regurgitation after radiofrequency catheter ablation of ventricular arrhythmia originating from a left ventricular papillary muscle

“…Yamada et al 3 reported that there was no evidence of significant MR after RF CA of PMs in 19 patients during a median follow-up period of 21 months (APM, n = 7; PPM, n = 12). Similarly, Rivera et al 5 reported that there was no increase in the incidence of MR or an increase in MR severity in 21 patients, including 5 patients with MVP, after CA of PMs using either cryoenergy (n = 12) or RF energy (n = 9). However, a case of bileaflet MVP and VT who developed severe MR after CA targeting PM-derived VA was reported by DeSimone et al 6 In the present case, MR worsened during an 8-month follow-up period.…”

“…Recently, a “malignant” arrhythmia phenotype in patients with mitral valve prolapse (MVP) who experienced life-threatening VAs has been reported. This subset of patients with MVP was characterized by complex ventricular ectopy arising from one or both of the PMs, fascicular tissue, and outflow tracts,1, 2 and the arrhythmias have been shown to be successfully treated by catheter ablation (CA) 3, 4, 5. Mitral valve dysfunction after radiofrequency (RF) CA of VAs of PM origin has been described in only 1 report, 6 to our knowledge.…”

Ventricular Arrhythmia Originating from the Left Ventricular Papillary Muscles: Clinical Features and Technical Aspects

“…With success defined as a ≥ 50% reduction in VAs, at a mean follow-up of 360 days, the cryoablation group had a 100% success rate versus a 56% success rate at 87 days followup in the RF group. 29 Cryoablation was also associated with a decrease in multiple VA morphologies observed during ablation (0% versus 77%).…”

“…18,24 With expanded use of cryoablation, circumferential ablation, and automatic pacemapping, current generation success rates are quoted to be as high as 90% to 100%. 27,29,31 These advances have rapidly transitioned ablation of papillary VA from one of the least successful ablation procedures to one of high probability of cure. The lessons learned from papillary muscle arrhythmia are being applied to other endocavitary structures and may help to improve procedural success rates elsewhere in the future.…”

Papillary Muscle Arrhythmias

“…Furthermore, a reduction of the PVC burden of <50% of the original PVC burden was used to define success in the study by Rivera et al, 3 whereas the standard definition of successful PVC ablation is a reduction of ≥80%.…”