Post-Infarction Ventricular Arrhythmias Originating in Papillary Muscles
Frank Bogun, MD*,
Benoit Desjardins, MD,
Thomas Crawford, MD,
Eric Good, DO,
Krit Jongnarangsin, MD,
Hakan Oral, MD,
Aman Chugh, MD,
Frank Pelosi, MD and
Fred Morady, MD
University of Michigan Medical Center, Ann Arbor, Michigan.
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Figure 1 Voltage Map
(Left) Voltage map of the posteromedial papillary muscle (PAP) in Patient #2, who had a prior inferior wall myocardial infarction involving this PAP. The site of origin of the premature ventricular complexes (PVCs) was the scar zone (voltage <1.0 mV), close to an area with higher voltage. (Right) Voltage map of the PAP within the voltage map of the remainder of the left ventricle. The left ventricular apex is cut away, allowing a view of the PAP and the posterolateral wall. MVA = mitral valve annulus.
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Figure 2 Measurement of Intracardiac Distance
Demonstration of measurement of the distance from the papillary muscle (PAP) to the nearest point of the endocardial shell at a site critical to a PAP arrhythmia. The distance here is 21 mm. LV = left ventricle.
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Figure 3 Intracardiac Echocardiography
(Left) Intracardiac echocardiogram demonstrating that the mapping/ablation catheter is in contact with the posteromedial papillary muscle (PAP) shown in Figures 1 and 2. (Right) Schematic of the intracardiac echocardiogram in the left panel. The mapping catheter (*), mitral valve annulus (MVA), and PAP are indicated.
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Figure 4 Electrograms of PAP-PVCs
(A) The 12-lead electrocardiogram of PVCs originating in the same posteromedial papillary muscle shown in Figures 1 and 2. (B) Local electrogram at the site of PVC origin in the posteromedial papillary muscle. The endocardial activation time is –38 ms. Note that the sinus rhythm electrogram at this site is fractionated and broad, extending beyond the end of the QRS complex. Abbreviations as in Figure 1.
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Figure 5 DEMRI Short-Axis Views
(A) Short-axis magnetic resonance imaging with delayed enhancement (DEMRI) of an anterior papillary muscle (PAP) with heterogeneous contrast uptake. The thin white arrow indicates the portion of the PAP head with contrast uptake, and the black arrow indicates the portion devoid of delayed enhancement. The posterior PAP shows homogeneous contrast uptake (thick white arrow). The heterogeneity index of the anterior PAP was 0.93, compared with 0 for the posterior PAP. (B) Short-axis DEMRI of PAPs without up-take of gadolinium.
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Figure 6 DEMRI Long-Axis Views
Two sequential longitudinal magnetic resonance imaging with delayed enhancement (DEMRI) cuts in Patient #2. There was heterogeneous uptake of contrast throughout the arrhythmogenic posteromedial papillary muscle (arrows).
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Figure 7 12-Lead Electrocardiograms of PAP-VTs
(A) A 12-lead electrocardiogram of a ventricular tachycardia (VT) (cycle length 275 ms) involving a posteromedial papillary muscle (PAP). There was a right bundle branch block morphology with superior axis and Q waves in the inferior leads. (B) A 12-lead electrocardiogram of a VT (CL 420 ms) involving an anterolateral PAP. There was a right bundle branch block morphology with inferior axis.
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