Successful Intracardiac Echocardiography–Guided Ablation of PVCs From the Posterior Papillary Muscle Chordae

Abstract

Introduction

Premature ventricular contractions (PVCs) originating from the papillary muscles and chordae tendineae represent a rare and challenging subtype of idiopathic ventricular arrhythmias. Their complex anatomical location and high mobility make mapping and catheter ablation particularly difficult.

Case Summary

A 46-year-old man presented with palpitations. Electrocardiogram and Holter monitoring revealed frequent monomorphic PVCs. Electroanatomic mapping with intracardiac echocardiography (ICE) guidance confirmed the origin at the chordae tendineae of the left posterior papillary muscle, where radiofrequency ablation was successfully performed.

Discussion

Papillary muscle and chordae-derived PVCs pose significant technical challenges due to complex anatomy and catheter instability. Integrated ICE guidance enables precise anatomical modeling and stable catheter contact, significantly improving procedural safety and efficacy while reducing the risk of damage to adjacent structures.

Take-Home Messages

For patients with PVCs exhibiting specific inferior lead and precordial patterns, papillary muscle/chordae origins should be considered. ICE-guided electroanatomic mapping is recommended to facilitate accurate localization and safe ablation of these complex arrhythmias.

Graphical Abstract

History of Presentation

A 46-year-old male presented with a 1-month recurrence of chest tightness and palpitations, accompanied by dizziness that led to a fall (without syncope or loss of consciousness). This symptom complex initially began 4 years ago, characterized by exertional chest tightness, palpitations, and dull precordial pain, typically provoked by walking approximately 1,000 m and relieved by rest. Initial cardiac evaluation at that time included a coronary angiogram, which showed no severe obstructive disease. Subsequent ambulatory monitoring revealed frequent premature ventricular contractions (PVCs) and episodes of nonsustained ventricular tachycardia. An electrophysiology study was performed and localized the origin of the arrhythmia to the left anterior papillary muscle. Radiofrequency ablation was performed and provided a significant reduction in arrhythmia burden; however, it was not possible to achieve complete elimination of all PVCs. Following the procedure, the patient experienced a period of symptomatic improvement until 1 month prior to the current presentation, when his symptoms recurred. A repeat electrocardiogram again showed frequent PVCs and nonsustained ventricular tachycardia.

Take-Home Message

• •For patients with premature ventricular contractions exhibiting specific inferior lead and precordial patterns, papillary muscle/chordae origins should be considered. Intracardiac echocardiography–guided electroanatomic mapping is recommended to facilitate accurate localization and safe ablation of these complex arrhythmias.

Past Medical History

His background is significant for hypertensive cardiomyopathy with consequent cardiac dilation and heart failure. He was diagnosed with coronary artery disease in August 2021 after an angiogram demonstrated a plaque in the mid-left anterior descending artery.

Differential Diagnosis

The differential diagnosis included acute coronary syndrome, worsening heart failure, sustained ventricular tachycardia, pulmonary embolism, and bradyarrhythmia.

Investigations

The electrocardiogram (ECG) demonstrates ventricular bigeminy, characterized by a repeating pattern wherein every sinus beat is followed by a premature, wide QRS complex without a preceding P wave (Supplemental Figure 1). The echocardiogram revealed severe left atrial and ventricular dilation, preserved ejection fraction (61%), severe mitral regurgitation, and moderate aortic regurgitation due to right coronary cusp prolapse. The radiological findings were consistent with cardiomegaly, while all laboratory investigations, including complete blood count, comprehensive metabolic panel, thyroid function tests, and cardiac enzyme assays, were within normal limits.

Management

After a thorough discussion with the patient, he opted to proceed with a repeat cardiac electrophysiology study and radiofrequency catheter ablation. As depicted in Figure 1, a detailed structural model of the left ventricle was constructed under intracardiac echocardiography (ICE) guidance. Pace mapping along the lateral branches of the left posterior papillary muscle revealed a matching morphology (Figure 2). Radiofrequency ablation was delivered from the base of the papillary muscle toward the chordae tendineae, which proved effective (Figure 3). During the procedure, a second PVC morphology (PVC 2) was frequently observed (Figure 4). Both PVCs exhibited a right bundle branch block pattern in lead V₁. Compared with PVC 1, PVC 2 showed deeper S-waves in the inferior leads (II, III, and aVF), as well as a taller, notched R-wave and a shallower S-wave in lead I. The morphologies of the 2 PVCs were generally similar across leads V₂ to V₆. Activation mapping identified the successful ablation site on the septal aspect of the left posterior papillary muscle (Figures 5 and 6). Following radiofrequency ablation, the targeted PVC was completely eliminated and remained noninducible during a 30-minute observation period and after intravenous isoproterenol infusion.

Figure 1.

3-Dimensional Electroanatomic Map of the Left Ventricle Guided by Intracardiac Echocardiography

Figure 2.

Activation Mapping Localizing the Premature Ventricular Contraction Origin to the Lateral Chordae of the Left Posterior Papillary Muscle

Figure 3.

Successful Ablation at the Lateral Chordae of the Left Posterior Papillary Muscle Under Intracardiac Echocardiography Guidance

Figure 4.

Two Morphologically Distinct Premature Ventricular Contractions Recorded Intraoperatively

Figure 5.

Activation Mapping Localizing the Second Premature Ventricular Contraction Origin to the Medial Chordae of the Left Posterior Papillary Muscle

Figure 6.

Successful Ablation at the Medial Chordae of the Left Posterior Papillary Muscle Under Intracardiac EchocardiographyGuidance

Discussion

This report presents the successful catheter ablation of symptomatic PVCs originating from the chordae tendineae of the left posterior papillary muscle—an exceptionally rare site of origin. A pivotal aspect of our strategy was the integration of ICE with a three-dimensional electroanatomic mapping system to construct a detailed anatomical model. This integration allowed rapid, safe, and precise delineation of the complex papillary muscle–chordae tendineae apparatus within the left ventricle. By providing a real-time anatomical roadmap, this approach facilitated accurate mapping and ablation while significantly reducing the risk of iatrogenic injury during catheter manipulation.

The technical challenges associated with ablating in this region are well recognized, including poor catheter stability, low signal-to-noise ratio with conventional mapping techniques, and the potential for damage to the mitral valve apparatus.^1,2 Traditional electroanatomic mapping alone often proves inadequate for navigating such delicate and highly mobile structures. In this case, the use of ICE from the outset offered several decisive advantages. First, it enhanced procedural safety: real-time visualization enabled continuous monitoring of catheter movement, preventing entanglement with chordae or unintended trauma to valve leaflets.³ Second, it improved efficiency and accuracy: ICE automatically delineates tissue-blood interfaces, enabling the rapid generation of a high-fidelity anatomical model—including the papillary muscles, chordae, and their ventricular connections—within minutes. This model proved substantially more anatomically accurate than one derived solely from contact force and local electrograms.⁴

Our experience underscores an efficient and safe workflow in which ICE is employed throughout the procedure. Initial anatomical modeling using ICE-integrated electroanatomic mapping is particularly valuable in complex regions such as this. Continuous intraoperative ICE guidance assists in catheter positioning and spatial orientation, helping to define critical structures and establish a safety zone prior to ablation. This approach not only shortens procedure and fluoroscopy time but, more importantly, reduces peri-procedural risks and helps prevent complications.⁵

The PVC morphology offered valuable initial localization clues: a right bundle branch block pattern in V₁, dominant S-waves in inferior leads (II, III, aVF), and an R/S ratio <1 in V₆ accurately directed attention to the inferobasal left ventricle, specifically the posterior papillary muscle region.⁶ This ECG signature helped focus mapping efforts, streamline the procedure, and minimize unnecessary manipulation in nontarget areas.

As a single-case report, our conclusions necessitate further validation through larger studies. Nonetheless, for symptomatic patients refractory to medical therapy, this case illustrates that an ICE-integrated approach—encompassing anatomical delineation, real-time navigation, stability monitoring during ablation, and precise pace mapping—represents a promising strategy for successful ablation of PVCs arising from the papillary muscle–chordae apparatus.

Conclusions

This case demonstrates that catheter ablation of PVCs originating from the posterior papillary muscle chordae is feasible and effective. Success was achieved through a combined approach of precise ECG localization and ICE-guided anatomical modeling, which enabled safe navigation and accurate ablation in this complex region. This strategy offers a valuable template for managing these challenging arrhythmias.

Funding Support and Author Disclosures

This study was supported by National Key R&D Program of China (2024ZD0521900), Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (ClFMS, 2021-I2M-1-063), and Noncommunicable Chronic Diseases-National Science and Technology Major Project (SQ2024AAA030109). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Supplemental Figure 1

12-Lead Electrocardiogram