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.