Pulsed field ablation using a multielectrode variable-loop circular catheter via a superior approach in a patient with dextrocardia, situs inversus, and interrupted inferior vena cava: a case report.

Background: Catheter ablation for atrial fibrillation (AF) in patients with dextrocardia, complete situs inversus, and interrupted inferior vena cava is technically demanding because of mirror-image cardiac anatomy and the absence of femoral venous access. Pulsed field ablation (PFA), a nonthermal and tissue-selective modality, may offer advantages in such challenging conditions. Case summary: A 53-year-old man with dextrocardia, complete situs inversus, and interrupted inferior vena cava with azygos continuation had previously undergone catheter ablation via the internal jugular vein. Three years later, recurrent symptomatic persistent AF led to repeat ablation. Using a superior approach under general anaesthesia, transseptal puncture was guided by intracardiac echocardiography. Electroanatomical mapping identified conduction gaps in the right pulmonary veins. A variable-loop circular catheter was used to eliminate the gaps. Posterior left atrial wall isolation was additionally performed to address the substrate for persistent AF. The procedure was completed without fluoroscopy. Discussion: To the best of our knowledge, this is the first report of AF ablation using a multielectrode variable-loop circular catheter via a superior approach without fluoroscopy. This strategy demonstrated the feasibility of PFA in the presence of mirrored cardiac anatomy. Impedance-based catheter-to-tissue contact assessment and lesion-visualization tools supported precise and acute lesion formation without fluoroscopy. These features emphasize the usefulness of pulsed field ablation when femoral venous access is limited.