Figura 1. Electrocardiogram. HR: 75 bpm – QRS axis: -50° – PQ: 120 ms - QRS: 80 ms - QT: 400 m...

Figura 2. Doppler echocardiogram. Image A: Apical four-chamber view, LVEF measurement with mild imp...

Figura 3. Cardiac magnetic resonance imaging. Image A: The arrow points to the interventricular sep...

Figura 4. Image A) RAO projection. Right coronary artery: dominant, without significant lesions. Ima...

Figura 5. Image A) LAO projection, caudal angulation: balloon positioning for pre-dilatation is visu...

Introduction

Dextrocardia with situs inversus totalis is a rare congenital anomaly in adults, affecting 1 in 10,000 people. It is characterized by a mirror-image arrangement of the heart relative to visceral structures. It poses a unique technical challenge in a field where interventional cardiologists lack experience1. While it is a rare clinical phenomenon, the frequency of coronary artery disease in these subjects is the same as in the general population2. There are few reports on patients with dextrocardia and associated coronary artery disease. Patients with dextrocardia who have undergone coronary angioplasty are even more unusual3.

The technical difficulties reported during this type of procedure have been diverse4.

Clinical case

The patient was a 62-year-old man with a medical history of dextrocardia with situs inversus totalis, arterial hypertension, and coronary artery disease with prior acute myocardial infarction (AMI) seven years ago, which was treated medically. He was under anti-ischemic treatment with bisoprolol 5 mg, enalapril 10 mg, and aspirin 100 mg. He consulted his primary care cardiologist for angina functional class II–III with two months of progression. An electrocardiogram showed no acute ischemic changes; however, it did show a negative lead I with the classic axis deviation in precordial leads (Figure 1).

A Doppler echocardiogram showed preserved diameters with mildly reduced left ventricular systolic function (left ventricular ejection fraction, LVEF), 47%, and hypokinesia of the anterior segments (Figure 2).

A cardiac magnetic resonance imaging showed a 47-% left ventricular ejection fraction, with preserved volumes and hypokinesia of the septoapical, anteroapical, lateroapical, and medial segments. Transmural enhancement was also detected in the septoapical and anteroapical segments, which was consistent with ischemic cardiomyopathy in the anterior descending artery (Figure 3).

Despite ongoing anti-ischemic treatment, the patient remained symptomatic, so cardiac catheterization was performed. It showed a severe lesion at the ostium of a large-caliber left anterior descending artery (Figure 4).

Due to the clinical context, a decision was made to conduct angioplasty on the ostium of the left anterior descending artery. Considering the technical difficulty of the case, it was performed using a transfemoral access, with a 6-Fr valved introducer according to technique. Prior to the procedure, the most appropriate technical approach was discussed in grand rounds. Literature review suggested the use of “mirror” projections, where each oblique line used for cannulation of the left main coronary artery in a regular patient had to be achieved in its exact opposite position. Catheter rotations also had to be exactly the opposite of those usually used.

The left coronary ostium was cannulated with a 6-Fr CONVEY EBU 3.5 (Boston Scientific, Massachusetts, USA) guidewire. Catheter choice was related to usual practice. The lesion was crossed with a 0.014” Singer Light wire (MEDTRONIC, Massachusetts, USA), which was positioned in the distal bed. Pre-dilatation was performed with a 2.5-×-15-mm semi-compliant EMERGE (Boston Scientific, Massachusetts, USA) coronary balloon at 10 atm. Subsequently, a 3.0-×-23-mm drug-eluting stent (DES) Firehawk (Micromedical, China) was implanted at 12 atm. Control angiography showed adequate stent expansion with good antegrade flow, without complications (Figure 5).

Discussion

The first cardiac catheterization in a patient with dextrocardia was reported in 1974, performed prior to a left ventricular aneurysmectomy< 1281>3< /1281>.

The first coronary angioplasty was described in 1987. In that publication, the author shared various technical tips4.

Available literature on technical adaptations to cardiac catheterization in patients with dextrocardia is scarce, and even less frequent in those who require percutaneous intervention5. In 1991, Blakenship compiled 10 cases, of which 4 were performed with Judkins catheters; 4 more used Sones catheters, and the remaining 2 successfully used Amplatz catheters6.In 1991, Lewis presented a case of angioplasty to the lateroventricular branch of the circumflex and the left anterior descending artery using Judkins guidewires in both cases7. In an article published in 2020, Marco Toselli proposes left radial access as a better alternative to right radial access8.

Our experience is similar to that of other authors, both regarding diagnosis and intervention. The main difficulties were catheter and angiographic projection selections. In this case, the diagnosis was made using 6-Fr right and left Judkins catheters, with some difficulty, using “mirror” projections as described by Blakenship6. Angioplasty was conducted with an extra support 6-Fr CONVEY 3.5 catheter, and stent implantation in the AD ostium was achieved with left oblique projection + caudal angulation and right oblique projection + axial angulation, with good results.

Conclusion

Dextrocardia is a rare phenomenon which, when present, increases the difficulty of both diagnosis and endovascular treatment of coronary disease. Available literature on the technical details for its resolution is scarce, posing a challenge for interventional cardiologists.

In such rare scenarios, interventional cardiologists must strive to prevail in their efforts to share their experience with colleagues. This will result in the enrichment of our specialty and the benefit of patients.

The use of “mirror” projections, opposite to the usual ones, using inverse rotation maneuvers, allowed for the procedure to be conducted successfully without major technical difficulties.

1. Rosemberg HN, Rosemberg IN. Simultaneous association of situs inversus, coronary heart disease, and hiatus hernia. Ann Intern Med 1949;30:851-9.

2. Hynes KM, Gau GT, Titus JL. Coronary heart disease in situs inversus totalis. Am J Cardiol 1973;31:666-9.

3. Moreyra AE, Saviano GJ, Kostis JB. Percutaneous transluminal coronary angioplasty in situs inversus. Cathet Cardiovasc Diagn 1987;13:114-6.

4. Richardson RL, Yousufuddin M, Eubanks DR. Ventricular aneurysm, arrhythmia, and open-heart operation in a patient with dextrocardia. Am Surg 1974;40:666-9.

5. Barış N, Kırımlı O, Ozpelit E, Akdeniz B. Right coronary artery intervention with mirror image in a patient with dextrocardia. Anadolu Kardiyol Derg 2005;4:340-1.

6. Blankenship JC, ramires JAF. Coronary arteriography in patients with dextrocardia. Cathet cardiovasc Diagn 1991;23:103-6.

7. Lewis BE, leya FS, Jones P, Grassman ED, Stasior C, Haryani V, et al. Successful directional coronary aterectomy in a patient wich situs inversus. Cathet Cardiovasc Diagn 1993;29:47-51.

   Toselli M, Solinas E, Vignali L. J Cardiovasc Med 2020,21:613-5.

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Endovascular treatment of an ostial lesion in dextrocardia: a technical and practical approach

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