Successful catheter ablation of persistent atrial fibrillation and common atrial flutter in a patient with dextrocardia, situs inversus, and interrupted inferior vena cava with azygos continuation

Figure 1. Electrocardiogram (ECG) and chest radiograph at admission. A: ECG showing the baseline rhythm as atrial fibrillation. B: Chest radiograph showing dextrocardia and enlarged cardiothoracic ratio at 52%. C: Right precordial leads of the ECG.

Figure 2. Computed tomography (CT) images. A: CT showed situs inversus totalis and dextrocardia. The inferior vena cava (IVC) did not drain into the morphologic right atrium (RA). The hepatic veins (arrow) entered the low RA. B: The superior vena cava (SVC) entered the high RA. The aorta (Ao) and the left atrium (LA) are also shown. C: The IVC continued to the azygos vein and then drained into the SVC. D: Three-dimensional CT showing the right anterior oblique (RAO) image of the aorta (Ao) and the LA. E: Three-dimensional CT showing the left anterior oblique (LAO) image of the azygos continuation (arrow) of the IVC that entered the RA via SVC.

Figure 3. Fluoroscopy and 3D navigation images during catheter ablation. A: When the transseptal needle was pushed, it kept slipping below the fossa ovalis. B: The septum was punctured and a guidewire was placed into the morphologic left atrium (LA). C: The integrated images of computed tomography and fluoroscopy on 3D navigation system showing the LA. An electrode catheter was placed in the morphologic right pulmonary vein (PV), and an ablation catheter was tightly curved and placed in the left PV. D: The integrated images after bilateral extensive PV isolation and linear ablation across the LA roof and posterior wall. E: After the rhythm transitioned to atrial flutter, the block line was made connecting the confluence of the hepatic vein at low right atrium (RA) and the tricuspid annulus (arrow). The right anterior oblique (RAO) image with coronary sinus (CS) is shown. F: The left anterior oblique (LAO) image.