A 65-year-old woman presented to our outpatientarrhythmia clinic with a complaint of palpitation. Shehad a history of surgical atrial septal defect closure manyyears earlier. Electrocardiography showed atrial flutter. Shehad consumed warfarin for several months. We decided toablate this arrhythmia. Transthoracic echocardiographydemonstrated a normal left ventricular size, mild leftventricular systolic dysfunction (ejection fraction=45%),right ventricular enlargement with mild systolic dysfunction,mild left and severe right atrial enlargement with severetricuspid regurgitation, and an estimated systolic pulmonarypressure of 35 mmHg. Additionally, an elongated Eustachianvalve (21 mm) was noted in the subcostal view (Figure 1). Inthe electrophysiology laboratory, no electrical activity wasrecorded when the ablating catheter was moved from theinferior vena cava up to the mid right atrium. Consequently,we injected a contrast medium into the inferior vena cava–right atrium in order to better visualize the inferior venacava and the right atrial anatomy in the anterior-posteriorprojection. A volcano-like inferior vena cava was illustrated,extending to the mid right atrium because of the elongatedEustachian valve (Figure 2). Electrophysiology studyrevealed isthmus-dependent lower loop atrial flutter, whichwas successfully ablated.
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