Implications of the anatomy of papillary muscle connections for mapping and ablation of focal ventricular arrhythmias

Background Ventricular arrhythmias (VAs) originating from papillary muscles (PAPs) can be challenging when targeted with catheter ablation. Reasons may include premature ventricular complex pleomorphism, structurally abnormal PAPs, or unusual origins of VAs from PAP–myocardial connections (PAP-MYCs). Objective The purpose of this study was to correlate PAP anatomy with mapping and ablation of PAP VAs. Methods In a series of 43 consecutive patients with frequent PAP arrhythmias referred for ablation, the anatomy and structure of PAPs and VA origins were analyzed using multimodality imaging. Successful ablation sites were analyzed for location on the PAP body or a PAP-MYC. Results In a total of 17 of 43 patients (40%), VAs originated from a PAP-MYC (in 5 of 17 patients, the PAP inserted into the mitral valve anulus); and in 41 patients, VAs originated from a PAP body. VAs from a PAP-MYC more often had delayed R-wave transition than did other PAP VAs (69% vs 28%; P < .001). Patients with failed procedures had more PAP-MYCs (24.8 ± 8 PAP-MYCs per patient vs 16 ± 7 PAP-MYCs per patient; P < .001). Conclusion Multimodality imaging identifies anatomic details of PAPs that facilitate mapping and ablation of VAs. In more than a third of patients with PAP VAs, VAs originate from connections between PAPs and the surrounding myocardium or between other PAPs. VA electrocardiographic morphologies are different when VAs originate from PAP-connection sites as compared with VAs originating from the PAP body. Ventricular arrhythmias (VAs) originating from papillary muscles (PAPs) can be challenging when targeted with catheter ablation. Reasons may include premature ventricular complex pleomorphism, structurally abnormal PAPs, or unusual origins of VAs from PAP–myocardial connections (PAP-MYCs). The purpose of this study was to correlate PAP anatomy with mapping and ablation of PAP VAs. In a series of 43 consecutive patients with frequent PAP arrhythmias referred for ablation, the anatomy and structure of PAPs and VA origins were analyzed using multimodality imaging. Successful ablation sites were analyzed for location on the PAP body or a PAP-MYC. In a total of 17 of 43 patients (40%), VAs originated from a PAP-MYC (in 5 of 17 patients, the PAP inserted into the mitral valve anulus); and in 41 patients, VAs originated from a PAP body. VAs from a PAP-MYC more often had delayed R-wave transition than did other PAP VAs (69% vs 28%; P < .001). Patients with failed procedures had more PAP-MYCs (24.8 ± 8 PAP-MYCs per patient vs 16 ± 7 PAP-MYCs per patient; P < .001). Multimodality imaging identifies anatomic details of PAPs that facilitate mapping and ablation of VAs. In more than a third of patients with PAP VAs, VAs originate from connections between PAPs and the surrounding myocardium or between other PAPs. VA electrocardiographic morphologies are different when VAs originate from PAP-connection sites as compared with VAs originating from the PAP body.