A rare case of superior approach for fluoroless atrial flutter ablation in a patient with dextrocardia, situs inversus, and interruption of the inferior vena cava

Figure 1. Electrocardiogram showed findings of dextrocardia with limb reversal in I and aVR as well as underlying atrial arrhythmia.

Figure 2. A: Right anterior oblique position showing the ablation catheter through the coronary sinus (CS) and on the cavotricuspid isthmus (CTI). Activation map in this projection shows a clockwise circuit around the tricuspid valve going through the CTI. B: Right-sided cranial view showing both the CS and the azygos vein emptying into the left-sided superior vena cava, which enters the right atrium from above. The remnant pouch of the inferior vena cava (IVC) can be seen in both these views. C: Intracardiac echocardiography image that can be seen in panels A and B shown in detail. Ablation catheter can be seen on the CTI between the tricuspid valve and the IVC pouch.

Figure 3. Right anterior oblique caudal projection showing ablation catheter extending from the coronary sinus and onto the cavotricuspid isthmus (CTI). The CTI is well defined between the tricuspid valve and remnant pouch. The pouch of the inferior vena cava (IVC) left in the right atrium is visualized. The decapolar catheter that was brought around from the femoral vein access through the left superior vena cava can also been seen later in the CTI. Pacing from this catheter confirmed the block along the CTI.