Provocative Cases -> Teaching Case Reports D-PO01 - Featured Poster Session (ID 11) Poster

D-PO01-112 - Catheter Ablation Of Premature Ventricular Contractions Originating From Kissing Papillary Muscles (ID 99)

 T. Yamada: Nothing relevant to disclose.


Background: Catheter ablation of ventricular arrhythmias originating from the papillary muscles is often challenging because their origins are located deep inside thick papillary muscles.
Objective: This case demonstrated an unusual type of challenge in catheter ablation of PVCs originating from thick papillary muscles.
Methods: N/A
Results: A 73-year-old woman with symptomatic idiopathic premature ventricular contractions (PVCs) underwent electrophysiological testing. At baseline, frequent PVCs exhibiting a right bundle branch block and right inferior axis QRS morphology were present. Pre-procedural cardiac magnetic resonance imaging and intracardiac echocardiography revealed very thick posteromedial and anterolateral papillary muscles (PPM and APM, respectively) in the left ventricle that were kissing each other during systole. Activation mapping was performed during the PVCs, but it was confusing because the earliest ventricular activation was recorded in the middle between the PPM and APM. Pace mapping was helpful for recognizing the location of the mapping catheter on the PPM or APM because the QRS axis dramatically changed between them. Radiofrequency catheter ablation was successful on the septal side of the APM where an excellent pace map was recorded. During more than 6 months of follow up, the patient has been free from any ventricular arrhythmias without any antiarrhythmic drugs. No complications occurred.
Conclusion: In this case, mapping of the PVCs originating from the papillary muscle was challenging because a very thick PPM and APM were kissing each other and the PVC origin was located on the septal side of the APM that faced the PPM.