Abstract
Background: Premature ventricular contractions (PVCs) originating from the papillary muscles are an uncommon but distinct type of ventricular arrhythmia. Their deep intramural origin, complex anatomy, preferential conduction pathways, and continuous motion of the papillary muscles during cardiac cycle pose significant challenges for catheter ablation, resulting in low success and high recurrence rates.
Case summary: We present the case of a 31-year-old female with recurrent PVCs and mild left ventricular dysfunction five months after an initial ablation procedure. Electrocardiography suggested a left ventricular papillary muscle origin. Three-dimensional electroanatomical mapping using the EnSite Precision™ system localized the earliest activation site to the anteriolateral papillary muscle. Radiofrequency ablation was performed with an irrigated contact force–sensing catheter (TactiCath™), achieving complete elimination of PVCs. At the one-month follow-up, the patient was asymptomatic, with a markedly reduced PVC burden and recovery of left ventricular ejection fraction from 46% to 58%.
Discussion: Papillary muscle–origin PVCs are often associated with complex Purkinje–myocardial interactions and anisotropic conduction, resulting in multiple exit sites and variable QRS morphologies. Successful ablation requires precise localization of the earliest activation, attention to Purkinje potentials or prepotentials, and stable catheter contact. Circumferential ablation around the papillary muscle base using an irrigated contact force–sensing catheter may improve long-term outcomes.
Conclusion: This case highlights the diagnostic and procedural challenges in managing papillary muscle–origin PVCs and emphasizes the importance of individualized mapping and ablation strategies to achieve durable rhythm control and functional recovery.