Papillary muscle-vt

Papillary Muscle Ventricular Arrhythmia

Date: April, 15, 2012

Speaker: Wen-Yu Lin

Institute: Tri-Service General Hospital

Advanced Cardiac Arrhythmia Training Course

Brief History

• A 59-year-old man with history of hypertension

• Habitus of cigarette smoking 1/2PPD for more than 30 years

• Alcohol consumption:-

• Betel nuts chewing:-

• He has previous VT attack since 2005 and ever received catheter ablation in Kaohsiung hospital

• But it recurred

Brief History

• June, 26, 2007 Admitted to Taipei VGH with diagnosis of left anterior fascicular ventricular tachycardia and underwent catheter ablation

• However, episodes of VT recurrence developed and he received DC shock at local hospital in Dec, 2010

• Dec, 22, 2010, he admitted to Taipei VGH again

• TTE showed LV EF: 52%, no obvious structural heart disease

Brief History

• Baseline sinus rhythm

• CAG: patency of coronary artery

2010/12/22 RV S1S2S3 (400/350/220) induced sustained VT

VA dissociation TCL:424ms QRS duration: 168msIt is also reproducible by RA S1S1

QRS morphology: RBBB pattern, right inferior axis, rS in lead I, R/S<1 in V6,QRS duration:168ms

During sinus rhythmArrow: Purkinje potential, 24ms before QRS

Reverse of Purkinje potential

But VT is reproducible again by RV extra-stimulus

RAO

LAO

LAO

Earliest site51ms earlier than QRS

NavX System

LAO

NavX System

Catheter ablation

ABL

ABL

CS

CS

RV

RV

HIS

HIS

Brief History

• October, 26, 2011 (10 months after procedure), VT attack again

• November, 28, 2011 He was admitted to Taipei VGH for repeated catheter ablation

• CAG: Patent coronary arteries

2011/11/28 RV S1S2S3S4 (400/350/300/250) induced sustained VTMorphology was quite similar compare with last-time VTTCL:440ms 2010/12/22

RAO

LAO

Voltage Map (Sinus rhythm) revealed relatively low voltage zone over anterior lateral wall of LV

2010/12/22 Ablation site

NavX System

After LV geometry and voltage map, we tried to induce VT againBut sustained VT could not be induced againSo we used pace map to find the optimal ablation site

LAO

ECG most compatible site

NavX System

ABL catheter: late potential

LAO

RAO

NavX System

Thermal trigger when radiofrequency ablation

Brief History • No further ventricular arrhythmia could be induced

by programmed stimulation (S1S2S3S4), commencing with Isoproterenol infusion

• Diagnosis:

Suspected left anterior papillary muscle ventricular tachycardia

• Follow-up:

March, 27, 2012: No clinical recurrence by medical

record

Papillary Muscle Ventricular Arrhythmia

Reference: 1. Circ Arrhythmia Electrophysiol. 2008;1:23-29.

2. Heart Rhythm, Vol 5, No 11, November 2008

3. J Cardiovasc Electrophysiol, Vol. 20, pp. 866-872, August 2009

4. J Cardiovasc Electrophysiol, Vol. 21, pp. 62-69, January 2010

Ventricular Tachycardia Originating From Posterior Papillary Muscle in the LV

Circ Arrhythm Electrophysiol 2008;1;23-29

Doppalapudi et al enrolled 290 consecutive patients who underwent ablation for VT or symptomatic PVCs.7 (2.4%) patients were found to have an ablation site at the base of posterior papillary muscle in the LV



Absence of high-frequency potential (Purkinje potential) in all patientsIrrigated catheter ablation was required



The earliest site of activation was localized to the base of the PPM in the LV

RAO

LAO

Ventricular arrhythmias originating from a papillary muscle: A comparison with fascicular arrhythmias

Fascicular VT(N=8)

Papillary VT(N=9)

P value

Age 31 ± 7 57 ± 9 <0.001

VT(n)/PVCs(n) 7/1 2/8 0.01

LV EF (%) 0.6 ± 0.07 0.49 ± 0.13 0.04

QRS duration 127 ± 11 150 ± 15 0.001

rsR’ in V1 8/8 0/11 <0.001

Q in limb leads 8/8 1/11 <0.001

Heart Rhythm, Vol 5, No 11, November 2008

Clinical and ECG characteristicsTotal 122 consecutive patients were enrolled


Fascicular VT(N=8)

Papillary VT(N=9)

P value

PP at effective site 8/8 5/11 0.01

PP-QRS interval during SR

-29 ± 5(before QRS)

+10 ± 17(after QRS)

0.002

Match pace map 0/8 10/11 <0.001

RF delivered (min) 7 ± 5 24 ± 12 0.003

Procedure time (min)

214 ± 50 368 ± 76 <0.001

Local voltage 6.2 ± 3.0 1.1 ± 0.8 <0.001


EP characteristics



More common in left posterior papillary muscle

7/9

2/9



ICE (Intra-cardiac echocardiogram) is a very helpful tool in recognizing and guiding radiofrequency ablation of papillary muscle ventricular arrhythmias

Idiopathic focal ventricular arrhythmias originating from the anterior papillary muscle

J Cardiovasc Electrophysiol, Vol. 20, pp. 866-872, August 2009



No Purkinje potentials were recorded at the ablation site during SR or VAsIrrigated catheter ablation is required for successful resultRecurrence attack by conventional 4-mm tip catheter ablation in 2 patients



Idiopathic Ventricular Arrhythmias Originating from the Papillary Muscles in the LV

• Yamada et al studies 159 consecutive patients with symptomatic idiopathic sustained VT, nonsustainedVT, or PVCs originating from LV

• Structural heart disease was excluded out

• Sites of origin of VA

Aortic root: 47 (29.6%) Epicardial: 17 (10.7%)

Aortomitral continuity: 12 (7.5%)

MA: 24 (15.1%) Fascicle: 38 (23.9%, LAF:8, LPF:30)

APM: 7 (4.4%) PPM: 12 (7.5%)

J Cardiovasc Electrophysiol, Vol. 21, pp. 62-69, January 2010



Anterolateral region LV VAs Posteromedial region LV VAs







• For anterolateral region:

an R/S ratio ≤1 in lead V6 in the LV anterolateral region could be the reliable predictors for differentiating APM VAs from LAF VAs

• For posteromedial region:

a QRS duration >160ms in LV posteroseptal region could be the predictors for differentiating PPM Vas from LPF VAs

• Irrigated or 8-mm tip ablation catheter is needed

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Catheter Ablation of Cardiac Arrhythmias, Second Edition

• 3-4% of idiopathic ventricular tachycardia

• Frequent PVCs are more common than sustained VT

• Papillary muscle VT should be considered if catheter ablation site around the structure

• Anterolateral papillary muscle:

RBBB, inferior axis

• Posteromedial papillary muscle:

RBBB, superior axis

• QRS duration was longer in PM VAs than fascicular VAs

Catheter Ablation of Cardiac Arrhythmias, Second Edition

• Absence of QS pattern in limb leads

• Absence of typical pre-Purkinje potential (P1) and Purkinje (P2)

• In anterolateral region, R/S<1 in V6 favor PM VTs

• In posteromedial region, QRS >160ms favor PM VTs

• If PM VT was considered, favor used irrigated or 8-mm tip catheter ablation for better successful results

• ICE should be used for optimal catheter contact if available

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Thanks for your attention

EARLIEST ACTIVATION, 46 MS, WITH VT NEST, POTENTIAL AND REVERSE OF BIPOLAR ELECTROGRAMS

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