Radiofrequency ablation of persistent atrial fibrillation in a patient with dextrocardia and interruption of inferior vena cava in the fluoroless catheterization laboratory: a case report.

BACKGROUND: Catheter ablation is an established therapy for atrial fibrillation, yet its application in patients with complex congenital cardiovascular anomalies remains challenging. Dextrocardia (1-2/20,000 incidence) and interruption of the inferior vena cava are rare structural abnormalities that complicate vascular access and catheter navigation during catheter ablation. CASE PRESENTATION: We report the case of a 39-year-old Chinese woman with persistent atrial fibrillation, dextrocardia, interruption of the inferior vena cava (with azygos continuation to the superior vena cava), severe mitral regurgitation, and pulmonary hypertension who underwent catheter ablation in the fluoroless catheterization laboratory. After thorough preoperative imaging assessment, we decided to perform the procedure through the right femoral vein and the left internal jugular vein approaches. Intracardiac echocardiography combined with the three-dimensional electroanatomic mapping method facilitated real-time visualization of the fossa ovalis and transseptal needle positioning without fluoroscopy. We safely completed the transseptal puncture by using this method. Pulmonary vein isolation and posterior wall box isolation were performed using a SmartTouch Surround Flow catheter, despite limited catheter maneuverability due to anatomical constraints. Successful sinus rhythm restoration was achieved without complications. At 3-month follow-up, the patient remained asymptomatic with a reduced left atrial diameter (57.7 mm to 51.2 mm) and stable sinus rhythm on electrocardiography. Integration of intracardiac echocardiography, three-dimensional electroanatomic mapping, and multidisciplinary planning enabled precise catheter ablation in the patient with complex anatomy. CONCLUSION: The results support fluoroless techniques as a viable option for atrial fibrillation ablation in challenging congenital anomalies, minimizing radiation exposure while maintaining procedural success.