Pulsed field ablation of atrial fibrillation via jugular transseptal puncture in a patient with dextrocardia and interrupted inferior vena cava: a case report.

Background: Situs viscerum inversus with dextrocardia and interrupted inferior vena cava (I-IVC) are rare congenital diseases that might challenge interventional procedures, such as transcatheter ablation for atrial fibrillation (AF), when transseptal puncture (TSP) is required for left atrial access. Recently, one-shot pulsed field ablation (PFA) has emerged as a safe and effective energy modality for AF ablation. We present a case report on jugular TSP guiding one-shot PFA in a patient presenting dextrocardia and an I-IVC, addressing the unique anatomical challenges. Case summary: A 52-year-old male with situs viscerum inversus with dextrocardia and I-IVC presented to our institution with symptomatic paroxysmal AF. Pre-procedural evaluation included transthoracic echocardiography and cardiac magnetic resonance (CMR) imaging. The PFA procedure was successfully performed under general anaesthesia guided by transoesophageal echocardiography (TOE), fluoroscopy, electroanatomical mapping and merging with CMR imaging. A transjugular TSP was specifically employed for vascular access due to the complex anatomy, allowing for efficient left atrial access and delivery of the ablation therapy. Discussion: Our case report highlights the role of multimodality pre-procedural imaging and the necessity of adapting procedural techniques, such as jugular TSP, to safely and effectively perform AF ablation in patients with complex congenital anatomy, as dextrocardia with I-IVC. The use of one-shot variable loop PFA catheter in such a challenging anatomical scenario allows an effective and safe treatment for transcatheter AF ablation in this case.