JACC Case Rep. 2026 Oct 16:110744. doi: 10.1016/j.jaccas.2026.110744. Online ahead of print.
ABSTRACT
BACKGROUND: Atrial fibrillation ablation in dextrocardia with interrupted inferior vena cava presents formidable technical challenges, particularly when anomalous systemic venous return distorts interatrial septal relationships.
CASE SUMMARY: A 58-year-old man with drug-refractory paroxysmal atrial fibrillation, situs inversus totalis with dextrocardia, and inferior vena cava interruption with azygos continuation to the coronary sinus underwent catheter ablation. Lacking an inferior route, a superior approach through the left internal jugular vein was selected. Under intracardiac echocardiography (ICE) guidance, transseptal access was obtained using a dedicated wire-based system. Pulmonary vein isolation and roofline ablation were safely completed using radiofrequency energy.
DISCUSSION: Azygos continuation to the coronary sinus drastically distorts interatrial geometry. ICE-guided, wire-based transseptal access via a superior route is a safe, practical alternative when conventional inferior access is unavailable and needle-based puncture poses high risks.
TAKE-HOME MESSAGES: In situs inversus, the left internal jugular vein offers an optimal trajectory for transseptal puncture via a superior approach. Using a dedicated transseptal guidewire instead of a rigid needle, strictly guided by ICE, reduces the risk of mechanical complications during atypical transseptal punctures in complex congenital heart disease.
PMID:42886137 | DOI:10.1016/j.jaccas.2026.110744