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Papillary Muscle Structural Abnormalities and Site of Origin of Arrhythmias
Quick Takes
- Multimodality imaging can identify papillary muscles that are the source of arrhythmias.
- Increased echogenicity, gadolinium enhancement, and calcifications on papillary muscles can indicate site of origin of an arrhythmia.
- Intracardiac echocardiography may be better than CT and MR in identifying site of origin of arrhythmia on papillary muscles.
Study Questions:
Does the finding of structural abnormalities on the papillary muscles have an association with site of origin of arrhythmias? Can multimodality imaging be of benefit in planning ablation procedures?
Methods:
A total of 43 patients referred for ablation for arrhythmias likely originating from the papillary muscles were studied consecutively. They received computed tomography (CT) angiography, magnetic resonance (MR), and intracardiac echocardiographic imaging. The structural abnormalities found were correlated with the origins of the ventricular arrhythmias.
Results:
In 74% of patients, at least one arrhythmia site was localized to an area of structural abnormality. A total of 141 sites of arrhythmia were identified. Increased intracardiac echogenicity was adjacent to target sites in 44% of those sites, adjacent to areas of increased gadolinium enhancement in 25% of those sites, and adjacent to calcifications in 10% of those sites. Of note, late gadolinium enhancement was found in 19 of 43 patients, calcifications on CT in 2 of 43, and calcification on intracardiac echocardiography in 39 of 43.
Conclusions:
Multimodality imaging that includes CT, MR, and intracardiac echocardiography can assist in identifying areas of origin of ventricular arrhythmias originating from the papillary muscles. Use of intracardiac echocardiography can better identify the sites when compared to MR and CT. The areas of calcification found on intracardiac echocardiography are closely related to ventricular arrhythmia target sites.
Perspective:
Since papillary muscle arrhythmias are often associated with structural abnormalities, it stands to reason that thorough imaging of these muscles can be valuable before an ablation procedure. This study of intensive advanced imaging of 43 consecutive patients shows that such imaging can be of great help in identifying target of origin of these arrhythmias. Moreover, intracardiac echo can find structural abnormalities not identified on CT and MR and may therefore have a particularly high benefit in directing ablation of the ventricular arrhythmia.
Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Ablation, Arrhythmias, Cardiac, Multimodal Imaging
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