Pulmonary Vein Isolation for Treatment of Paroxysmal Atrial Fibrillation on Patient with Situs Inversus Totalis
G.A. Gromyko1,2, S.U. Mihaylichenko2, S.A. Novichkov2, D.A. Mangutov2, D.L. Kranin2, E.V. Krukov2
1I.M. Sechenov First Moscow State Medical University.2FSGE «Burdenko Main Military Clinical Hospital» of Russian Federation Defense Ministry.
A 56-year-old male with paroxysmal atrial fibrillation refractory to class IC and class III antiarrhythmic drugs was admitted to our hospital for radiofrequency catheter ablation of atrial fibrillation. During preoperative examination situs inversus totalis was revealed. Pulmonary vein (PV) isolation was successfully performed with atrial fibrillation termination and elimination of all PV potentials. The procedure was performed without any complications. Our report shows that PV isolation for treatment of drug-refractory atrial fibrillation can be safely performed in patients with dextrocardia and situs inversus totalis.
Key Words : Atrial fibrillation, Pulmonary veins isolation, Dextrocordia.
Correspondence to: Grigorii Gromyko(firstname.lastname@example.org)
Recently, pulmonary vein isolation (PVI) has become a common procedure for the treatment of drug-refractory paroxysmal atrial fibrillation (AFIB). The presence of abnormal anatomy can make the procedure more complex. There are limited data about the feasibility and safety of PVI in patients with situs inversus totalis.
A 56-year-old male with 10-year anamnesis of paroxysmal AFib was admitted to our hospital. Episodes of atrial fibrillation were highly symptomatic, appeared two to four times per month, lasted for two to three hours and were terminated by beta blockers or amiodarone. Chronic antiarrhythmic therapy with class IC and class III drugs was ineffective for AFib prevention. During preoperative examination dextrocardia and situs inversus totalis were revealed.
According to current guidelines  radiofrequency ablation (RFA) targeting PV was considered. The procedure was performed using intracardiac echocardiography (ICE) and the CARTO 3 (Biosense Webster) navigation system. Two Swarz SR0 introducers and an 11Fr introducer for ICE were inserted via the left femoral vein. A double transseptal puncture was performed under ICE control. Angiography [Figure 1] and 3D reconstruction [Figure 2] of the left atrium were performed. When a Lasso catheter was positioned in the anatomical right superior PV prominent left atrial appendage, potentials were registered. Atrial fibrillation was induced during manipulations near the left superior PV.
Angiography of left atrium from long sheath, positioned in left superior (anatomical right) pulmonary vein
Reconstruction of left atrium from electroanatomical mapping system with ablation points
Point-by-point antral isolation of all pulmonary veins was performed using a bi-directional SmartTouch catheter (Biosense Webster), with termination of AFib during anatomical left superior PV isolation and elimination of all PV potentials, confirmed by Lasso catheter. The procedure duration was 85 minutes; fluoroscopy time – 4 minutes 35 seconds. There were no complications during the procedure.
There are few case reports of successful PVI in patients with situs inversus totalis using RF energy ,, cryoenergy  or robotic navigation . In our case report, because of ICE-assisted transseptal puncture and the use of an electroanatomical mapping system, short procedure duration and low X-ray exposure were achieved. Catheter and long sheath manipulations are complex in cases of heart inversion since the positions of the tools are opposite to those for the case of common anatomy. The use of the SmartTouch catheter can facilitate the procedure performance, especially in the left atrial ridge area. The right-sided position of the left atrial appendage makes it more difficult to achieve good catheter-to-tissue contact in the left atrial ridge area.
Pulmonary vein isolation for the treatment of drug-refractory paroxysmal atrial fibrillation can be safely performed in patients with situs inversus totalis.