Three-dimensional electroanatomical mapping for non-pulmonary vein foci in a patient with complete situs inversus and dextrocardia

Fig. 1. A: Chest radiography and 64-slice multidetector computed tomography (CT) show mirror-image dextrocardia. B: Three-dimensional reconstruction of the RA and LA according to CT images. LA = left atrium; RA = right atrium; LAA = left atrial appendage; CS = coronary sinus; Ao = aorta; LSPV = left superior pulmonary vein; LIPV = left inferior pulmonary vein; RSPV = right superior pulmonary vein; RIPV = right inferior pulmonary vein.

Fig. 2. A: Direct contrast injection into the LA and PV through the transseptal sheath in left posterior oblique (35°) and right anterior oblique (45°) views. B: Three-dimensional reconstruction of the RA and LA according to CT images from the same oblique views. LA = left atrium; RA = right atrium; PV = pulmonary vein; LAA = left atrial appendage; CS = coronary sinus; RSPV = right superior pulmonary vein; RAO = right anterior oblique; LAO = left anterior oblique.

Fig. 3. A: Sinus rhythm and premature atrial contractions (PACs) on standard 12-lead electrocardiography (ECG) (standard limb and left-sided precordial lead positions). The P-wave morphology of the PACs is positive in leads III and V1, negative in leads I and II, isoelectric in lead aVL. B: Sinus rhythm and PACs on opposite 12-lead ECG (left-right reversal limb and right-sided precordial lead positions). The P-wave morphology of the PACs is positive in leads I, II, and V1, isoelectric in lead aVL, and negative in lead III (* PAC).

Fig. 4. A: Biatrial standard local activation time mapping during premature atrial contractions (PACs) in left posterior oblique (30°) and right anterior oblique (45°) views. The color-coded activation sequence is shown in white to blue, demonstrating the earliest to latest excitation sites. A single area showing the earliest activation is located at the middle of the RA septal region (left-sided). B: Catheter position at the successful ablation site in the left posterior oblique view (50°). The red dots depict the ablation line of PV isolation. The orange dot depicts the successful ablation site of the PACs. The bonus radiofrequency energy application sites are shown by the green dots. The earliest activation at the left-sided mid right atrial septum preceded the onset of the surface P wave by 63 msec. SVC = superior vena cava; RA = right atrium; LA = left atrium; CS = coronary sinus; LAA = left atrial appendage; TA = tricuspid annulus; RSPV = right superior pulmonary vein; RIPV = right inferior pulmonary vein.

Fig. 5. Incessant premature atrial contractions (PACs) were terminated 3.8 seconds after the beginning of radiofrequency current application.