Ventricular Tachycardia Originating From the Posterior Papillary Muscle in the Left Ventricle

Abstract

Background-Several distinct forms of focal ventricular tachycardia (VT) from the left ventricle (LV) have been described. We report a new syndrome of VT arising from the base of the posterior papillary muscle in the LV. Methods and Results-Among 290 consecutive patients who underwent ablation for VT or symptomatic premature ventricular complexes (PVCs) based on a focal mechanism, 7 patients were found to have an ablation site at the base of the posterior papillary muscle in the LV. All patients had normal LV systolic function and a normal baseline electrocardiogram. The electrocardiogram during VT or PVCs demonstrated a right bundle-branch block and superior-axis QRS morphology in all patients. VT was not inducible by programmed atrial or ventricular stimulation. In 2 patients with sustained VT, overdrive pacing neither terminated VT nor demonstrated any criterion for transient entrainment. Activation mapping localized the earliest site of activation to the base of the posterior papillary muscle in all patients. When Purkinje potentials were recorded at the site of successful ablation, these potentials preceded local ventricular muscle potentials during sinus rhythm. During VT or PVCs, however, the ventricular muscle potential always preceded the Purkinje potentials. After recurrence of VT or PVCs with standard radiofrequency ablation, irrigated ablation was successful in eliminating the arrhythmia in all patients. Over a mean follow-up period of 9 months, all patients have been free of PVCs and VT. Conclusion-We present a distinct syndrome of VT arising from the base of the posterior papillary muscle in the LV by a nonreentrant mechanism. Ablation can be challenging, and irrigated ablation may be necessary for long-term success.

2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

“…U małej liczby pacjentów idiopatyczne VT lub PVC mogą się wywodzić z mięśnia brodawkowatego RV lub LV [576][577][578]. Jeżeli arytmia wywodzi się z lewego tylnego mięśnia brodawkowatego, to zwykle ma morfologię RBBB z osią elektryczną w płaszczyźnie czołowej skierowaną w górę i w prawo lub w lewo, a czas trwania zespołu QRS > 150 ms [576].…”

“…Jeżeli arytmia wywodzi się z lewego tylnego mięśnia brodawkowatego, to zwykle ma morfologię RBBB z osią elektryczną w płaszczyźnie czołowej skierowaną w górę i w prawo lub w lewo, a czas trwania zespołu QRS > 150 ms [576]. Ablacja przezcewnikowa PVC lub VT z mięśnia brodawkowatego jest skuteczną metodą leczenia w przypadku braku odpowiedzi na leki blokujące kanały sodowe (klasa IC) i/lub beta-adrenolityki [578].…”

Differentiation of Papillary Muscle From Fascicular and Mitral Annular Ventricular Arrhythmias in Patients With and Without Structural Heart Disease

“…[1][2][3][4] VAs originating from the papillary muscles have been shown to exhibit distinct clinical and electrocardiographic features. [1][2][3][4][5][6] Given that papillary muscles are anatomically complex structures, catheter ablation of Pap VAs can be challenging and are associated with lower success rates than ablation of left ventricular fascicular arrhythmias. 6 Studies on the differentiation of Pap VAs from other idiopathic left VAs, such as mitral annular (MA) VAs, are lacking.…”

Anatomical Consideration in Catheter Ablation of Idiopathic Ventricular Arrhythmias

“…three-dimensional mapping system should be used as a guide for mapping. [16][17][18]31 Patients with papillary muscle IVAs often exhibit variable QRS morphologies spontaneously and/or after the initial ablation lesions. 18 The altered QRS morphologies of papillary muscle IVAs after the ablation may guide the following mapping and catheter ablation.…”

“…7,8 Tricuspid annular IVAs can originate from any region along the tricuspid annulus, but more often originate from the septal aspect, especially in the anteroseptal or para-Hisian region than the free wall. 15 IVAs can arise from intracavitary structures including the papillary muscles [16][17][18][19][20] and moderator band. 21 LV papillary muscle IVAs are known to arise more commonly from the postero-medial papillary muscle than the anterolateral papillary muscle.…”