Zero-Fluoroscopy Radiofrequency Ablation of a Right Ventricular Outflow Tract PVC in a Patient With Situs Inversus Totalis: When Precision Matters.

Background: Congenital cardiac anomalies present unique challenges for adult cardiac electrophysiologists, particularly when attempting complex ablation procedures. Case Summary: We report the case of a 60-year-old male with situs inversus totalis who presented with symptomatic, high-burden premature ventricular complexes (PVCs) refractory to medical therapy. Using reversed (mirror-image) precordial lead placement, high-definition 3D electroanatomic mapping, and intracardiac echocardiography, successful radiofrequency ablation was achieved using a completely zero-fluoroscopy approach. Discussion: In patients with congenital cardiac anomalies, the applicability of zero-fluoroscopy strategies is often limited because of their complex anatomy. Successful management requires in-depth anatomical understanding and carefully adapted procedural techniques. This case highlights that even in the setting of significant anatomical variation, a systematic zero-fluoroscopy approach can lead to effective and safe outcomes. Take‐Home Message: Zero-fluoroscopy PVC radiofrequency ablation using high-definition 3D mapping and intracardiac echocardiography is a feasible and safe approach, even in anatomically challenging cases such as situs inversus.