Case Report: Angiography-guided transvenous single-chamber pacemaker implantation in mirror-image dextrocardia with congenitally corrected transposition of the great arteries.

Abstract

Background: Mirror-image dextrocardia with situs inversus is uncommon. Transvenous permanent pacemaker implantation is technically demanding when it coexists with congenitally corrected transposition of the great arteries (ccTGA), because venous access, atrioventricular valve crossing, and fluoroscopic lead orientation may differ from usual anatomy.

Case presentation: A 61-year-old man was admitted with recurrent dizziness and palpitations for 5 years; his symptoms had worsened during the preceding 2 weeks. Preoperative 12-lead electrocardiography showed atrial fibrillation with a slow ventricular response. Twenty-four-hour Holter monitoring documented 707 pauses longer than 2.0 s, with a longest R-R interval of 6.13 s. Echocardiography confirmed mirror-image dextrocardia, situs inversus, and ccTGA. A single-chamber permanent pacemaker was implanted through the right axillary vein. Posteroanterior fluoroscopy defined the right-sided cardiac silhouette; right axillary venography guided venous puncture; right atrial angiography identified the morphologic mitral annular plane; and multi-projection fluoroscopy was used to confirm the final ventricular lead position in the high mid-septal region of the morphologic left ventricle. The procedure lasted 56 min and had no acute complications. At 6-month outpatient follow-up, standard 12-lead electrocardiography, 24-hour Holter monitoring, formal device interrogation, and transthoracic echocardiography showed stable pacing, preserved ventricular performance, and no device-related complication; the paced QRS duration was 144 ms and the pacing burden was 99.8%. During telephone follow-up in June 2026, approximately 1 year after implantation, the patient reported no discomfort.

Conclusion: This case describes a structured approach to conventional transvenous pacemaker implantation in mirror-image dextrocardia with ccTGA. In this patient, venography, chamber angiography, and targeted fluoroscopic views reduced procedural uncertainty, and follow-up through 1 year showed clinical stability without recognized complications.