1. Advanced Cardiac Arrhythmia
Training Course
Papillary Muscle Ventricular Arrhythmia
Date: April, 15, 2012
Speaker: Wen-Yu Lin
Institute: Tri-Service General Hospital

2. 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

3. 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

4. Brief History
• Baseline sinus rhythm
• CAG: patency of coronary artery

5. 2010/12/22 RV S1S2S3 (400/350/220) induced sustained VT
VA dissociation TCL:424ms QRS duration: 168ms
It is also reproducible by RA S1S1

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

7. During sinus rhythm
Arrow: Purkinje potential, 24ms before QRS

8. Reverse of Purkinje potential

9. But VT is reproducible again by RV extra-stimulus

10. NavX System
RAO
LA
O
Earliest site
51ms earlier
than QRS
LAO

11. NavX System
HIS
RV
CS ABL
LAO
HIS
ABL
RV
CS
Catheter ablation

12. 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

13. 2011/11/28 RV S1S2S3S4 (400/350/300/250) induced sustained VT
Morphology was quite similar compare with last-time VT
TCL:440ms 2010/12/22

14. NavX System
2010/12/22 Ablation site
RAO
Voltage Map (Sinus rhythm)
revealed relatively low voltage
zone over anterior lateral wall
LAO of LV

15. After LV geometry and voltage map, we tried to induce VT again
But sustained VT could not be induced again
So we used pace map to find the optimal ablation site

16. NavX System
ECG most compatible site
ABL catheter:
LAO late potential

17. NavX System
RAO
LAO Thermal trigger when
radiofrequency ablation

18. 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

19. 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

20. Ventricular Tachycardia Originating From Posterior
Papillary Muscle in the LV
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 Circ Arrhythm Electrophysiol 2008;1;23-29

21. Ventricular Tachycardia Originating From Posterior
Papillary Muscle in the LV
Absence of high-frequency potential (Purkinje potential) in all patients
Irrigated catheter ablation was required
Circ Arrhythm Electrophysiol 2008;1;23-29

22. Ventricular Tachycardia Originating From Posterior
Papillary Muscle in the LV
The earliest site of activation was
localized to the base of the PPM
in the LV
RAO
LAO
Circ Arrhythm Electrophysiol 2008;1;23-29

23. Heart Rhythm, Vol 5, No 11, November 2008
Ventricular arrhythmias originating from a papillary
muscle: A comparison with fascicular arrhythmias
Clinical and ECG characteristics
Total 122 consecutive patients were enrolled
Fascicular VT Papillary VT P value
(N=8) (N=9)
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

24. Heart Rhythm, Vol 5, No 11, November 2008
Ventricular arrhythmias originating from a papillary
muscle: A comparison with fascicular arrhythmias
EP characteristics
Fascicular VT Papillary VT P value
(N=8) (N=9)
PP at effective site 8/8 5/11 0.01
PP-QRS interval -29 ± 5 +10 ± 17 0.002
during SR (before QRS) (after QRS)
Match pace map 0/8 10/11 <0.001
RF delivered (min) 7±5 24 ± 12 0.003
Procedure time 214 ± 50 368 ± 76 <0.001
(min)
Local voltage 6.2 ± 3.0 1.1 ± 0.8 <0.001

25. Ventricular arrhythmias originating from a papillary
muscle: A comparison with fascicular arrhythmias
2/9
7/9
More common in left posterior
papillary muscle
Heart Rhythm, Vol 5, No 11, November 2008

26. Ventricular arrhythmias originating from a papillary
muscle: A comparison with fascicular arrhythmias
ICE (Intra-cardiac echocardiogram) is a very helpful tool in
recognizing and guiding radiofrequency ablation of papillary
muscle ventricular arrhythmias
Heart Rhythm, Vol 5, No 11, November 2008

27. Idiopathic focal ventricular arrhythmias
originating from the anterior papillary muscle
J Cardiovasc Electrophysiol, Vol. 20, pp. 866-872, August 2009

28. Idiopathic focal ventricular arrhythmias
originating from the anterior papillary muscle
No Purkinje potentials were recorded at the ablation site during SR or VAs
Irrigated catheter ablation is required for successful result
Recurrence attack by conventional 4-mm tip catheter ablation in 2 patients
J Cardiovasc Electrophysiol, Vol. 20, pp. 866-872, August 2009

29. Idiopathic focal ventricular arrhythmias
originating from the anterior papillary muscle
J Cardiovasc Electrophysiol, Vol. 20, pp. 866-872, August 2009

30. Idiopathic Ventricular Arrhythmias Originating
from the Papillary Muscles in the LV
• Yamada et al studies 159 consecutive patients with
symptomatic idiopathic sustained VT, nonsustained
VT, 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

31. Idiopathic Ventricular Arrhythmias Originating
from the Papillary Muscles in the LV
Anterolateral region LV VAs Posteromedial region LV VAs
J Cardiovasc Electrophysiol, Vol. 21, pp. 62-69, January 2010

32. Idiopathic Ventricular Arrhythmias Originating
from the Papillary Muscles in the LV
J Cardiovasc Electrophysiol, Vol. 21, pp. 62-69, January 2010

33. Idiopathic Ventricular Arrhythmias Originating
from the Papillary Muscles in the LV
J Cardiovasc Electrophysiol, Vol. 21, pp. 62-69, January 2010

34. Idiopathic Ventricular Arrhythmias Originating
from the Papillary Muscles in the LV
• 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
J Cardiovasc Electrophysiol, Vol. 21, pp. 62-69, January 2010

35. Share with you (1)
• 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

36. Share with you (2)
• 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
Catheter Ablation of Cardiac Arrhythmias, Second Edition

37. Thanks for your attention

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