Figure 1 - uploaded by Nicolas Vecchio
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Cardiac resonance is showing the different papillary muscle connection (PMC) types. A, Anterolateral papillary muscle (ALPM) without PMCs. B, PMC type I A. C, PMC type I B (red arrow: lateral strand and blue arrow: medial strand). D, PMC type II (yellow arrow). E, PMC type III A (red arrows). The blue arrow corresponds to a type IV B PMC. F, PMC Type III B. G, PMC type IV A (yellow arrow). H, PMC type IV B (blue arrow). I, LV PMs with both type IV A (pink arrows) and IV B (yellow arrow) PMCs.
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Background:
Papillary muscles (PM) ventricular arrhythmias (VAs) exhibit QRS variability, attributed to anisotropy. ECG inconsistencies such as late precordial transition (TZ) and discordant QRS axis may not be solely explained by anisotropic conduction. We sought to determine the presence of anatomic connections of the PM and correlate them with...
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Background
Catheter ablation is recommended in patients with frequent and symptomatic ventricular arrhythmias (VAs) in an otherwise normal heart. Right or left outflow tract (OT) are the most common origins, and catheter ablation is highly effective with low complication rates. However, outcome of catheter ablation of VAs other than the OT (non-OTV...
Citations
... Left ventricular (LV) dilatation causes greater sphericity and changes the location and orientation of papillary muscles (PMs), which may influence their ability to do work (Duchenne et al., 2019). According to Santiago Rivera et al., 2019, papillary muscles are widespread in patients with ventricular arrhythmias (VA) (Rivera et al., 2019). ...
... Left ventricular (LV) dilatation causes greater sphericity and changes the location and orientation of papillary muscles (PMs), which may influence their ability to do work (Duchenne et al., 2019). According to Santiago Rivera et al., 2019, papillary muscles are widespread in patients with ventricular arrhythmias (VA) (Rivera et al., 2019). ...
Papillary muscles are one of the important components of the musculature of the ventricles of the heart. Various diseases of papillary muscle dysfunction such as papillary muscle ischemia, left ventricular dilation, non-ischemic papillary muscle atrophy, papillary muscle or chordae congenital anomalies, dilated or hypertrophic cardiomegaly are commonly observed. Apparently normal postmortem hearts (n=60) were used in this study. Based on gender, specimens were grouped as follows: group A (n=41) ‘male’ and group B (n=19) ‘female’. The length and breadth of the anterior, posterior and septal papillary muscles were measured. The mean length of the anterior papillary muscle was 17.27 (±4.30) mm in males, 16.98 (±3.70) mm in females, the posterior papillary muscle was 14.04 (±3.78) mm in males, and 13.81 (±2.47) mm in female, and septal papillary muscle was 7.35 (±2.78) mm in male and 6.73 (±1.94) mm in female. The breadth of anterior papillary muscle was 5.75 (±1.24) mm and 5.94 (±1.76) mm, posterior papillary had 5.02 (±1.09) mm and 4.77 (±0.80) mm, and septal papillary was 3.97 (±0.81) mm and 3.86 (±0.38) mm in male and female accordingly.
... Left ventricular (LV) dilatation causes greater sphericity and changes the location and orientation of papillary muscles (PMs), which may influence their ability to do work (Duchenne et al., 2019). According to Santiago Rivera et al., 2019, papillary muscles are widespread in patients with ventricular arrhythmias (VA) (Rivera et al., 2019). ...
... Left ventricular (LV) dilatation causes greater sphericity and changes the location and orientation of papillary muscles (PMs), which may influence their ability to do work (Duchenne et al., 2019). According to Santiago Rivera et al., 2019, papillary muscles are widespread in patients with ventricular arrhythmias (VA) (Rivera et al., 2019). ...
Papillary muscles are one of the important components of the musculature of the ventricles of the heart. Various diseases of papillary muscle dysfunction such as papillary muscle ischemia, left ventricular dilation, non-ischemic papillary muscle atrophy, papillary muscle or chordae congenital anomalies, dilated or hypertrophic cardiomegaly are commonly observed. Apparently normal postmortem hearts (n=60) were used in this study. Based on gender, specimens were grouped as follows: group A (n=41) ‘male’ and group B (n=19) ‘female’. The length and breadth of the anterior, posterior and septal papillary muscles were measured. The mean length of the anterior papillary muscle was 17.27 (±4.30) mm in males, 16.98 (±3.70) mm in females, the posterior papillary muscle was 14.04 (±3.78) mm in males, and 13.81 (±2.47) mm in female, and septal papillary muscle was 7.35 (±2.78) mm in male and 6.73 (±1.94) mm in female. The breadth of anterior papillary muscle was 5.75 (±1.24) mm and 5.94 (±1.76) mm, posterior papillary had 5.02 (±1.09) mm and 4.77 (±0.80) mm, and septal papillary was 3.97 (±0.81) mm and 3.86 (±0.38) mm in male and female accordingly.
... The large decrease in long-term as compared to the acute procedural results of this approach may be related to inadequate size and deepness of RF lesions, or to the presence of anatomical connections among PM body and left ventricular wall, relatively far from PM base. Indeed, Rivera et al.34 recently described prevalence and clinical significance of PM connections (PMCs), detected at cardiac magnetic resonance (CMR) in patients undergone PM ablation. The prevalence of PMCs among patients experiencing arrhythmia recurrences was as high as 91%, suggesting that preferential conduction through either the PM base or PMCs may exist and may contribute to recurrences at follow-up. ...
Background:
Catheter ablation of papillary muscle ventricular arrhythmias (PM-VAs) has been associated with unsatisfactory results. Features that may affect acute and long-term procedural outcomes are not well established.
Objective:
To systematically review the available data in the literature assessing efficacy and safety of PM-VAs catheter ablation.
Methods:
An online search of Pubmed, Cochrane Registry, Web of Science, Scopus and EMBASE libraries (from inception to March, 1 2021) was performed, in addition to manual screening. Twenty-one observational non-controlled case-series were considered eligible for the systematic review, including 536 patients.
Results:
Postero-medial PM harbored 60.8% of PM-VAs, while antero-lateral PM and right ventricular PMs 34.9% and 4.3% of cases, respectively. The mean acute success rate of the index ablation procedure was 88.1% (95% CI 82.8%-91.9%, p < 0.001, I2 0%). After a mean follow-up period of 15.5 ± 17.4 months, pooled long-term arrhythmia-free rate was 69.2%, while the pooled long-term success rate after multiple ablation procedure was 84.9%. Overall, procedure complications occurred in 9 patients (1.7%) and no procedure-related deaths were reported. The use of intracardiac echocardiography (ICE) as well as contact force sensing (CFS) and irrigated catheters during ablation was associated with higher rates of arrhythmia-freedom at long-term follow-up.
Conclusions:
Catheter ablation is an effective and safe strategy for PM-VAs, with an acute success rate of 88.1%, a long-term success rate of 69.2%, with a relatively low procedural complication rate. The use of ICE, irrigated catheters and catheters with CFS capability was associated with higher rates of arrhythmia-freedom at long-term follow-up. This article is protected by copyright. All rights reserved.
... This complex network has been known to be related to the mechanism of ventricular tachyarrhythmias [10,11]. The anatomic variation of the HPS and its relationship with papillary muscles have been associated with increased incidence of ventricular tachyarrhythmias [12,13]. Until now, there has been no way to observe the distribution of the HPS during catheter ablation for ventricular tachyarrhythmias. ...
... In addition, arrhythmia occurring in the papillary muscle and arrhythmia associated with the fascicle are difficult to evaluate because clinical symptoms are not significantly different [20]. Recently, Rivera et al. reported a muscular connection between papillary muscles, which are related to the electrocardiographic pattern in papillary muscle related ventricular tachyarrhythmias [12]. To ablate the focal area of fascicular reentrant or Purkinje fiber-related ventricular tachycardia, precise anatomic and electrical mapping is important [21]. ...
Background:
The distribution and connection of ventricular Purkinje fibers are known to be associated with idiopathic left ventricular arrhythmias. Unusual anatomy is one of the important factors associated with catheter ablation success rate. With the widefield high-speed, swept-source optical coherence microscopy (OCM) and light microscope, we visualized the left ventricular Purkinje fiber distribution.
Methods:
Left ventricular walls of five adult ovine hearts were incised from the mitral annulus to the apex. Using the widefield OCM technique and light microscopy, we observed the distribution, direction, depth, and dividing patterns of the Purkinje network with multiple tangential angles and without tissue destruction.
Results:
Widefield OCM was used to characterize the ovine heart Purkinje network system in a 4 × 4 mm2 field. Left ventricular Purkinje fibers traveled in the sub-endocardial area near the left-sided peri-membranous septal area and ran like a wide hair bundle. The distal branching fibers penetrated to the endocardium and connected to the contractile muscle. In this distal area, Purkinje fibers were connected to each other, forming multiple layers. Some Purkinje fibers were directly connected within the false tendon between the papillary muscles or between the trabeculations. Some free-running Purkinje fibers were directly connected to the papillary muscle from the left bundle.
Conclusion:
Using widefield OCM, we were able to observe the left bundle and its branching patterns in ovine left ventricle without tissue destruction. This might be applied to future cardiac ablation procedures.
Background: The anterior and lateral position of the anterolateral papillary muscle (ALPM) has found to be reached with better catheter stability and less mechanical bumping via the transseptal (TS) compared to the retrograde aortic (RA) approach. Aim: To compare the TS and RA approaches on mapping and ablation of ventricular arrhythmias (VAs) arising from ALPMs. Methods: Thirty-two patients with ALPM-VAs undergoing mapping and ablation via the TS approach were included and compared with 31 patients via the RA approach within the same period. Acute success was compared, as well as other outcomes including misinterpreted mapping results due to bumping, radiofrequency (RF) attempts, procedural time and success rate at 12 months’ follow-up. Results: Acute success was achieved in more cases in the TS group (96.4% vs 72.0%, P=0.020). During activation mapping, bump-provoked premature ventricular complexes (PVCs) misinterpreted as clinical PVCs were more common in the RA group (30.0% vs 58.3%, P=0.036), leading to more RF attempts (3.5±2.7 vs 7.2±6.8, P=0.006). Suppression of VAs were finally achieved in the unsuccessful cases by changing to the alternative approach, but the procedural time was significantly less in the TS group (90.0±33.0 vs 113.7±41.1min, P=0.027) with less need to change the approach, although follow-up success rates were similar (75.0% vs 71.0%, P=0.718). Conclusion: A TS rather than RA approach as the initial approach appears to facilitate mapping and ablation of ALPM-VAs, specifically by decreasing the possibility of misleading mapping results caused by bump-provoked PVC, and increase the acute success rate thereby.
Hypertrophic cardiomyopathy is a common inherited cardiac condition in which regional myocardial thickening and scarring can lead to a range of symptoms including breathlessness, dizziness, chest pain, and collapse with loss of consciousness. It is vital to be able to understand the mechanisms behind these epiphenomena and to be able to distinguish, for example, between syncope because of arrhythmia versus syncope because of mechanical outflow tract obstruction. Therefore, we require a technique that can characterize anatomy, physiology, and myocardial substrate. Traditionally, this role has been the preserve of cardiac magnetic resonance (CMR) imaging. This review makes the case for cardiac computed tomography (CT) as an alternative imaging method. We review the use of functional CT to identify the components of outflow tract obstruction (and obstruction at other levels, which may be simultaneous), and as an aid to interventional and surgical planning. We demonstrate the added value of multiplanar isotropic reformats in this condition, particularly in cases where the diagnosis may be more challenging or where complications (such as early apical aneurysm) may be difficult to recognize with 2-dimensional techniques. In conclusion, our aim is to convince readers that cardiac CT is a highly valuable and versatile tool, which deserves wider usage and greater recognition in those caring for patients with hypertrophic cardiomyopathy.
Background:
Ventricular Arrhythmias (VA) originating from papillary muscles (PAP) can be challenging when targeted with catheter ablation. Reasons may include PVC pleomorphism, structurally abnormal PAPs, or unusual origins of VAs from PAP-myocardial connections (PAP-MYC).
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 /43 patients (40%) VAs originated from a PAP-MYC (in 5/17 the PAP inserted into the mitral anulus) and in 41 patients the VAs originated from a PAP body. VAs from PAP-MYC more often had delayed R wave transition than other PAP VAs (69% vs 28%, p<0.001). Patients with failed procedures had more PAP-MYCs connections (24.8±8 vs 16±7 PAP-MYCs per patient, p<0.001).
Conclusions:
Multimodality imaging identifies anatomic details of papillary muscles that facilitate mapping and ablation of ventricular arrhythmias. In more than a third of patients with PAP VAs, the VAs originate from connections between PAPs and the surrounding myocardium or between PAPs. VA ECG morphologies are different when VAs originate from PAP-connection sites compared to VAs originating from the PAP body.
BACKGROUND The papillary muscle basal connections have significant clinical implications. Variety of studies done on its morphology and function by various specialists in different departments. A close look on these revealed the interconnections of papillary muscles to one another and to the interventricular septum of both ventricles is related to uncoordinated contractions of papillary muscles, leading to hyper or hypokinesia or prolapse or even its rupture. METHODS Our study done in 25 formalin soaked hearts revealed after the deep and meticulous dissection, reflecting the walls of ventricles laterally the numerous interconnections of papillary muscles at its bases and IVS. Ventricles are opened by inverted ‘L’ shaped incision and its reflected more laterally till all the papillary muscles is visible in one frame after incising the moderator band. The connections were noted, measured, photographed, tabulated, compared with similar studies and analysed with experts with respective fields. RESULTS Almost all the specimens did have the interconnections. Further the post mortem findings of the cardiac related deaths with involvement of papillary muscles suggest damage to such ‘bridges’. The moderator band extensions to the base of right APM, and its extension to the posterior groups is noted in all the specimens. The bridge from the IVS to bases of both the groups of papillary muscles is noted in left ventricle. In90% of specimens the one PPM is found to be loosely connected, more so in left ventricle. CONCLUSIONS We are of a conclusion that such basal interconnections and to the interventricular septum are responsible for rhythmic contractions of papillary muscles of both ventricles. Since the AV valves have to open simultaneously, interconnections becomes mandatory as the impulse has to reach it before it reaches the trabeculae carniae. One of the Posterior papillary muscles is loosely connected to other papillary muscles, may be the reason for its rupture, more so in left ventricle. KEYWORDS Papillary Muscle, Interbasal Connection, Moderator Band, Valvular Prolapse, AV Valves
Objectives
This study sought to address whether technological innovations such as contact force sensing (CFS) can improve acute and long-term ablation outcomes of left ventricular papillary muscle (LV PAP) ventricular arrhythmias (VAs).
Background
Catheter ablation of LV PAP VAs has been less efficacious than another focal VAs. It remains unclear whether technological innovations such as CFS can improve acute and long-term ablation outcomes of LV PAP VA.
Methods
From January 2015 to December 2019, a total of 137 patients underwent LV PAP VA ablation. VA site of origin (SOO) was identified using activation and pace-mapping guided by intracardiac echocardiography. Radiofrequency energy (20 to 50 W for 60 to 90 s) was delivered by irrigated catheter with or without CFS. We defined acute success as complete suppression of targeted VA ≥30 min post ablation and clinical success as ≥80% VA burden reduction at outpatient follow-up.
Results
VA manifested as premature ventricular complexes in 98 (71%), nonsustained ventricular tachycardia in 18 (13%), sustained ventricular tachycardia in 12 (9%) and premature ventricular complexes induced ventricular fibrillation in 9 (7%). VA SOO was anterolateral PAP in 51 (37%), posteromedial PAP in 73 (53%), and both PAPs in 13 (10%). VAs were targeted using CFS in 97 (71%) and non-CFS in 40 (29%). After a single procedure, acute success was achieved in 130 (95%) and clinical success was achieved in 112 (82%); neither was impacted by VA SOO and/or CFS. Complications occurred in 5 patients (3.6%).
Conclusion
Independent of CFS technology, intracardiac echocardiography-guided catheter ablation is highly efficacious and may be considered as first-line therapy in the management of LV PAP VA.
