Ablation of premature ventricle contraction arising from papillary muscle without intracardiac echo using point by point mapping

Jasmin Popara (Kiel)1, V. Maslova (Kiel)1, A. Zaman (Kiel)1, L. Sprenger (Kiel)1, L. Kleinhans (Norderstedt)2, O. Jahn (Norderstedt)2, D. Frank (Kiel)1, T. Demming (Kiel)1, R. Pantlik (Bad Bevensen)3, E. Lyan (Kiel)1

1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; 2Biosense Webster, Johnson & Johnson Norderstedt, Deutschland; 3Herz- und Gefäßzentrum Bad Bevensen Bad Bevensen, Deutschland


Background: Catheter radiofrequency ablation (RFA) of ventricular arrhythmias (VAs) arising from the left ventricle's papillary muscles (PM) has been associated with inconsistent results due to difficulties in 3D reconstruction of this intraventricular structure. The use of intracardiac echo allows for 2D visualisation of the PM and the guiding of ablation catheter. Cryo energy allows stable contact with the target structure during ablation. These two techniques have been shown to increase the success rate of ablation (77% reported1) but don’t allow the construction of the 3D map of papillary muscle with activation during PVC. Using a combination of point-by-point mapping (PbP) along with “fast anatomical mapping” (FAM) (Carto® 3 system) allows 3D reconstruction of the PM geometry with activation. These may increase the accuracy of PVC origin targeting.

Aim: This study aims to assess the feasibility and success rate of RFA of PVC arising from the papillary muscles of the left ventricle. 

Methods and results: We retrospectively analysed 214 patients treated with RFA for PVCs in two institutions. PVC arose from PM in 12(5.6%) cases (65±20 years old; 42% males; 33% with ejection fraction>50%; 8.3% antero-lateral PM). Initial detailed FAM of the left ventricle was performed using PVC pattern matching via transaortic or transmitral approach. Then, all points with preexcitation to QRS onset were copied from FAM into the new PbP map. That automatically created the geometry of PM with an activation map inside the LV shell. Irrigated high power (50W) RFA was performed at the site of earliest activation at the PM shell. The acute success rate was 75% (n=9) without complications. PVC recurrence at 12-month follow-up was 11% (n=1 out of 9).

Conclusions: RFA of PVC arising from papillary muscles using point-by-point mapping is feasible and associated with a success rate comparable to the previously reported one when intracardiac echo-guided ablation is used.

Figure 1. Point-by-point activation map of postero-septal papillary muscle inside the left ventricle mesh. The ablation target is the earliest site at the top of the papillary muscle.

1. Rivera S. Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle, Guided by Intracardiac Echocardiography and Image Integration. Circ Arrhythm Electrophysiol. 2016 Apr;9(4):e003874. doi: 10.1161/CIRCEP.115.003874. 
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