Situs inversus with dextrocardia is a congenital condition in which the heart is a mirror image of the anatomically normal heart on the right side. A patient presented with the sick sinus syndrome accompanying mirror image dextrocardia which was associated with double superior vena cava and a left sided inferior vena cava A permanent transvenous demand pacemaker was inserted because of repeated episodes of dizziness and a single episode of syncope with ECG showing bradycardia with junctional escape rhythm. Precise knowledge of the venous system and the location of the apex of the right ventricle were necessary prior to permanent pacemaker implantation. Without such knowledge pacing may be technically challenging.