Abstract
The discovery, characterization, and ablation of the papillary muscles have evolved rapidly since the initial description in 2008. New innovations in pacemapping, intracardiac imaging, ablation catheters, and ablation methodologies have dramatically impacted the approach to the treatment of papillary muscle ventricular arrhythmias. This review provides an up-to-date summary of these methods, as well as guidance on how to integrate them into clinical practice.
Highlights
The advent of electroanatomic mapping, intracardiac echocardiography, and multidetector computed tomo graphy has led to the improvement of the identification and localization of endocavitary ventricular arrhythmias (VAs)
The moderator band, tricuspid valve, papillary muscles, and false tendons have been identified as origins of VAs.[3,4]
The anterolateral and posterolateral papillary muscles have been confirmed as origins of ventricular tachycardia (VT)
Summary
The advent of electroanatomic mapping, intracardiac echocardiography, and multidetector computed tomo graphy has led to the improvement of the identification and localization of endocavitary ventricular arrhythmias (VAs). Found that premature ventricular contractions (PVCs) may be triggers of ventricular fibrillation[15] and that papillary PVCs may induce a cardio myopathy, which may be corrected with ablation.[16,17] These observations have led to a comprehensive understanding of the mechanism of papillary muscle VA. Papillary VA is an automatic or triggered focal arrhythmia, which often originates in the deep layers of the myocardium This is supported by the pattern of induction by exercise, isoproterenol usage, lack of entrainment, tendency against sustained VT, late diastolic activation time at the ablation site, lack of fractionated potentials at the ablation site,[18] acceleration with radiofrequency (RF) energy application,[13] and the observation that the first beat of the tachycardia has the same morphology as subsequent beats. Evidence supporting a deep myocardial source include (1) the requirement for irrigated catheters for ablation; (2) poor results with pacemapping (completed far from the breakout site)[20]; and (3) a lack of interruption of VT with mechanical stimulation.[18]
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