Effective alcohol septal ablation for left ventricular outflow tract obstruction in a patient with isolated dextrocardia

Isolated dextrocardia is a congenital anomaly characterised by the normal position of the thoracic and abdominal viscera with a right cardiac apex. Left ventricular outflow tract obstruction (LVOTO) is a common structural manifestation of hypertrophic cardiomyopathy (HCM). A 65-year-old woman had worsening chest discomfort and dyspnoea on exertion. Chest CT angiography identified the isolated dextrocardia and HCM. Colour Doppler echocardiography showed mosaic flow in the LV outflow, indicating LVOTO. We performed alcohol septal ablation (ASA) under intracardiac echocardiography (ICE)-guided selective myocardial contrasting. This procedure improved provoked intra-LV pressure gradient by Valsalva manoeuvre and nitroglycerin injection from 136 to 50 mm Hg and her symptoms. The unique combination of isolated dextrocardia and left ventricular hypertrophy could have been involved in the formation of latent LVOTO. Even with the anomaly, contrast ICE made it possible to clarify the target septal left ventricular wall of ASA, and we could perform ASA safely.