Pulsed field ablation for paroxysmal atrial fibrillation and atrial flutter in a patient with dextrocardia and prior secundum atrial septal defect repair: a case report

Pulsed field ablation (PFA) is a novel non-thermal ablation modality that has demonstrated efficacy and safety in the treatment of common arrhythmias such as atrial fibrillation (AF) and atrial flutter (AFL). However, evidence regarding its use in patients with dextrocardia remains scarce.

A 63-year-old woman with dextrocardia and situs in vs. totalis, and with prior surgical atrial septal defect (ASD) repair, presented with heart palpitations that did not respond to antiarrhythmic drugs. Ambulatory and Holter monitoring documented short episodes of AF and AFL. Computed tomography (CT) of the heart and its structures before the procedure enabled anatomical orientation and planning of the procedure. Catheter ablation was performed using a Pentaspline PFA system (FARAPULSE, Boston Scientific) under fluoroscopic guidance without electroanatomical mapping. Pulmonary vein isolation, along with ablation of the left atrial roof, posterior wall of the left atrium, and cavotricuspid isthmus, was successfully achieved. The procedure was successful, and no recurrence of arrhythmia was observed on 6-month Holter monitoring.

This case demonstrates that combined PFA for AF and AFL is feasible in patients with complex congenital anatomy, including dextrocardia following ASD repair. Mirror-image cardiac anatomy presents unique challenges for catheter navigation and anatomical orientation. Pre-procedural cardiac CT was essential for procedural planning and accurate spatial orientation, facilitating successful PFA in this anatomically complex setting.