A 46-year-old female was referred for catheter ablation of symptomatic, drug-refractory atrial fibrillation (AF). Left atrial diameter was 52 mm. Chest radiography demonstrated the right-sided heart (Panel A). Cardiac magnetic resonance imaging classified this as dextrocardia (base to apex pointing to the right) with situs solitus (normal visceral situs with concordant atrial situs, Panel B). The morphological right ventricle, identified by the presence of the moderator band, coarse apical trabeculations, and infundibulum, was connected to the right atrium (concordant atrioventricular connections) confirming normal so-called D-loop ventricular development and orientation (Panel C). Ventriculo-arterial connections were also concordant (aorta located left and posterior to pulmonary artery).
Circumferential pulmonary vein (PV) isolation was performed for the treatment of AF. Double transseptal access was achieved under transoesophageal echocardiography guidance. Following selective PV angiography and rotational angiography of the left atrium and PVs, a three-dimensional electroanatomical reconstruction of the left atrium was created using the CARTO 3 system (Biosense Webster, Diamond Bar, CA, USA). Bilateral circumferential ablation lines were deployed around the ipsilateral PV ostia using the SenseiTM (Hansen Medical, Mountain View, CA, USA) robotic navigation system (Panel D). Isolation of all PVs verified by decapolar lasso catheter recordings was achieved without complications.
Dextrocardia with situs solitus, D-loop ventricles, and normally related great arteries results from failure of the ventricles to shift leftwards during embryological development. Relative to its normal position, the heart appears to be rotated towards the right haemithorax. This explains the relative posterior position of the morphological right atrium and ventricle in relation to the corresponding left-sided chambers.
To the best of our knowledge, this is the first report illustrating successful PV isolation in a patient with dextrocardia with situs solitus, D-loop ventricles, and normally related great arteries. Additionally, catheter ablation was performed using a robotic navigation system. In summary, PV isolation in patients with dextrocardia, situs solitus, D-loop ventricles, and normally related great arteries are feasible after careful attention to anatomical detail or proper periprocedural visualization of anatomical structures.
The authors thank Dr Björn Peters for his thoughtful review of the manuscript and helpful suggestions.
Panel A Chest radiograph shows the right-sided heart with discordant location of the cardiac apex relative to liver shadow and stomach. The site of liver shadow and gastric bubble is consistent with situs solitus.
Panel B Cardiac magnetic resonance imaging scan scanning the plane of outflow tract of the left ventricle (LV) demonstrating fibrous continuity between inflow mitral valve and outflow aortic valve. Note that in contradiction to conventional anatomy, the LV is located anterior and inferior to the right ventricle (RV) (LA, left atrium; AO, aorta).
Panel C Image from cardiac magnetic resonance imaging scan: axial image through cardiac chambers. The morphological RV can be identified by the moderator band (arrow).
Panel D Three-dimensional electroanatomical reconstruction of the left atrium using the CARTO system in posterior anterior projection. Red dots indicate the ablation line around the pulmonary veins.
