Hepatic vein access for pulmonary vein isolation in patients without femoral vein access

Key Teaching Points•The present report describes 3 cases of pulmonary vein isolation in patients with interrupted inferior vena cava (IVC) necessitating hepatic vein access for ablation.•The hepatic vein approach is an alternative method of obtaining venous access for ablation procedures when femoral access is not possible due to venous occlusion or venous malformations seen in heterotaxy syndrome.•Heterotaxy syndrome is associated with atrial fibrillation as well as interrupted IVC.•While obtaining hepatic vein access for ablation, one should be aware of the posterior course of the hepatic vein when draining into the right atrium, resulting in a more anterior placement of the transseptal needle on the septum than expected.•No changes in anticoagulation regimen prior to the procedure are needed using this approach. •The present report describes 3 cases of pulmonary vein isolation in patients with interrupted inferior vena cava (IVC) necessitating hepatic vein access for ablation.•The hepatic vein approach is an alternative method of obtaining venous access for ablation procedures when femoral access is not possible due to venous occlusion or venous malformations seen in heterotaxy syndrome.•Heterotaxy syndrome is associated with atrial fibrillation as well as interrupted IVC.•While obtaining hepatic vein access for ablation, one should be aware of the posterior course of the hepatic vein when draining into the right atrium, resulting in a more anterior placement of the transseptal needle on the septum than expected.•No changes in anticoagulation regimen prior to the procedure are needed using this approach.