Papillary Muscle Arrhythmias: To Freeze or to Burn, That Is the Question.

Abstract

Technological advances during the past decade have significantly enhanced our ability to successfully map and ablate ventricular arrhythmias in patients with a structurally normal heart, as well as various forms of underlying cardiac disease. Increased recognition of the deleterious effects of ventricular arrhythmias, such as the potential of frequent premature ventricular complexes (PVCs) to induce cardiomyopathy, has increased indications for ablation. Successful outcomes of catheter ablation of ventricular arrhythmias are subject to many potential challenges and reported with variable rates of success. See Article by Rivera et al Patient selection for ablation of ventricular arrhythmias should reflect symptom severity, effect of the ventricular arrhythmia on underlying cardiac substrate, effectiveness and side effects of medical therapy, and expected safety and efficacy of ablation. Challenges to a successful ablation include lack of inducibility of the arrhythmia, inability to effectively access the ablation target (ie, intramural or epicardial location), and risk of collateral damage with ablation (ie, the coronary arteries or the conduction system). The papillary muscles create a unique challenge by presenting a target on a mobile and intracavitary structure. In a recent large-scale multicenter outcomes analysis of ablation of idiopathic PVCs, the significant predictors of procedure failure included number of PVC morphologies and PVC location. Epicardial and papillary muscle sites of origin represented the locations with lowest acute procedural success (67% and 80%, respectively). At follow-up, patients with papillary muscle PVCs had among the highest recurrence rate with only 60% of patients maintaining a successful outcome of 80% reduction in PVC burden without the use of …