case_images: PMC11694671_01
case_images: Initial electrocardiogram showing the run of ventricular tachycardia.
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case_images: The patient's ECG showed repetitive runs of ventricular tachycardia (VT), with QRS morphology suggesting an origin in the posteromedial papillary muscle (Figure 1).
case_images: (A) Intracardiac echocardiography showing the ablation catheter's position at the base of the anterolateral papillary muscle. (B) Termination of ventricular tachycardia during ablation. (C) Local activation time map demonstrating activation in the anterolateral papillary muscle. (D) Intracardial signals showing the earliest signals in the ablation catheter. Abl, ablation; AL, anterolateral; AP, anteroposterior; CS, coronary sinus.
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case_images: A local activation map was created of premature ventricular complexes (PVCs) with the same morphology on 12-lead ECG as clinical runs of VT, and it showed the earliest activation at the posterior base of the anterolateral papillary muscle rather than the posteromedial papillary muscle (Figure 2C). The difference between the 'typical' ECG pattern for papillary muscle PVC and the true origin of the VT can be explained by the relatively small left ventricle and a slightly abnormal position of the anterolateral papillary muscle, which was more posterior than usual on intracardiac echocardiography (Figure 2A). During the radiofrequency ablation procedure, spontaneously induced VT terminated, and no further ectopic activity was observed (Figure 2B).
case_images: Chest X-ray (anteroposterior view) after the first implantation.
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case_images: The procedure was performed using the standard transvenous approach, and the defibrillation lead was placed to where the basal septum of the right ventricle was thought to be located with excellent parameters (Figure 3).
case_images: Computed tomography showing lead perforation through the pericardium to the intercostal muscle. (A) Initial topogram. (B) Sagittal view. (C) Transversal view. (D) Frontal view.
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case_images: Computed tomography revealed that the lead passed through the right ventricle, pericardium, and intercostal muscles, causing a perforation (Figure 4).
case_images: Periprocedural X-ray (anteroposterior view) during the second implantation.
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case_images: The extraction procedure was followed by the immediate implantation of a new transvenous lead in a different position more towards the septum (Figure 5).