Radiofrequency ablation of long-standing persistent atrial fibrillation in a patient with dextrocardia, interrupted inferior vena cava and mirrored persistent left superior vena cava

INTRODUCTION: Catheter ablation is an established treatment for atrial fibrillation (AF). However, AF ablation in patients with complex congenital anatomical variants, including mirror dextrocardia, interrupted inferior vena cava (IVC), and persistent left superior vena cava (PLSVC), remains technically challenging, with limited published clinical experience. CASE PRESENTATION: We report a 60-year-old female patient with long-standing persistent AF and heart failure with reduced ejection fraction, who had mirror dextrocardia, interrupted IVC, and PLSVC. The procedure was performed via a left internal jugular vein approach for transseptal puncture and ablation. The strategy included bilateral pulmonary vein isolation, linear ablation of the left atrial roof, mitral isthmus, and hepatic venous - tricuspid isthmus, plus electrical isolation of the PLSVC, all guided by intracardiac echocardiography and electroanatomic mapping. OUTCOMES: At 17 months of follow-up, the patient remained asymptomatic with no documented atrial arrhythmia recurrence. Left ventricular ejection fraction improved from 36% to 46%. CONCLUSIONS: This single case demonstrates that in patients with complex anatomical variants and long-standing persistent AF, AF ablation incorporating targeted PLSVC electrical isolation via a left internal jugular vein approach under intracardiac echocardiography guidance is feasible, safe, and clinically effective. Further experience is needed to confirm the generalizability of this strategy.