Abstract
Percutaneous coronary intervention in patients with dextrocardia presents several challenges due to abnormal location of the heart, mirror image pattern of aortic arch and its branches, and abnormal coronary origin and orientation. The challenges involve appropriate choice of vascular access, guiding catheters, engagement technique, acquisition and interpretation of radiological orientation of coronary anatomy, and appropriate radiological angles and views. We report a patient with dextrocardia and situs inversus who presented with acute ST segment elevation myocardial infarction and was successfully treated with trans-radial primary percutaneous coronary intervention using “double inversion technique.” We also emphasize that left radial artery approach may be technically preferred to right radial artery approach due to mirror image aortic arch branching pattern.
<Learning objective: 1. Percutaneous coronary intervention in patients with dextrocardia presents several challenges due to abnormal location of the heart, mirror image pattern of aortic arch and its branches, and abnormal coronary origin and orientation. 2. These challenges can be overcome by “double inversion technique,” which allows the operator to interpret coronary anatomy and perform intervention as in levocardia.>
Keywords: Acute myocardial infarction, Angiographic views, Dextrocardia, Double inversion technique, Trans-radial intervention
Introduction
People with dextrocardia share the same risk as the general population for ischemic heart disease. Performing percutaneous coronary intervention in patients with dextrocardia presents several challenges to the interventional cardiologist due to unfamiliarity with abnormal radiological orientation of coronary anatomy and need for modified views. In 2005 we described the advantage of the “double inversion technique” [1], which could correct the unfamiliar angulated pictures of the coronary tree in dextrocardia into the familiar conventional angiographic pictures of a normally located heart.
Case report
A 58-year-old man was admitted with acute chest pain associated with perspiration for 4 h. His risks for coronary artery disease included long standing hypertension and obesity. He reported that the chest pain was on the right side with radiation to the right shoulder. Cardiovascular examination revealed apical impulse on the right side with palpable S4. Electrocardiography demonstrated an inverted P wave in leads I and aVL and an upright P wave and R wave in aVR, with reverse progression of R waves in the precordial leads with ST segment elevation in leads II, III, and aVF. Reciprocal dextrocardia with inferior wall hypokinesia was confirmed with echocardiography and troponin-I was elevated, thus confirming the diagnosis of acute inferior ST elevation myocardial infarction.
Loading doses of aspirin (325 mg) and clopidogrel (600 mg) were given and he was emergently transferred to the cardiac catheterization laboratory for primary angioplasty. The procedure was done through the right radial artery approach with a 6 French system (Fr) and a biplane Siemens image intensifier (Siemens Healthcare, Mountain View, CA, USA). We followed the double inversion technique to acquire angiographic views. The images acquired using combination of right-left reversal with “horizontal sweep reverse” button on angiographic equipment and reversal of right anterior oblique/left anterior oblique (RAO/LAO) projections keeping the cranial/caudal tilts same. There was difficulty in negotiating the catheter into the aortic sinus through the right radial artery due to abnormal mirror image right sided aortic arch (Fig. 1, Video 1). The Optitorque catheter (Terumo, Japan) was used for diagnostic angiography. There was no difficulty in acquiring diagnostic coronary angiographic images. The left anterior descending and circumflex arteries were normal. The right coronary artery (RCA) was dominant and had critical stenosis in mid RCA with distal thrombolysis in myocardial infarction (TIMI) II flow (Fig. 2, Video 2).
Fig. 1.
Aortic angiography in right anterior oblique view showing mirror image pattern right-sided aortic arch.
Fig. 2.
Right coronary artery (RCA) injection in right anterior oblique view 50° showing critical disease in mid RCA. The anatomy simulates RCA injection in conventional left anterior oblique projection.
We decided to perform angioplasty to RCA stenosis. The diagnostic catheter was exchanged over the wire to an extra support guide catheter (ECR 3.5, 6F; Medtronic, Minneapolis, MN, USA) and the RCA was hooked by anticlockwise torque. The lesion was crossed with Balanced Middle Weight wire (BMW; Abbott Vascular, Abbott Park, IL, USA) flipping between the simultaneous biplane RAO and LAO views. The RAO-cranial view, however, was the best to show the full profile of the vessel which simulated LAO view in a normally positioned heart. The lesion was dilated with 2.5 mm × 10 mm semi-compliant balloon and stented with 3 mm × 28 mm Cypher (Cordis, Miami, FL, USA) and distal TIMI III flow (Fig. 3, Fig. 4, Videos 3 and 4) was achieved. The total amount of contrast used was 145 ml and fluoroscopic time was 9 min 30 s. He was discharged with dual antiplatelets, atorvastatin and was asymptomatic at 6 months follow-up.
Fig. 3.
Post angioplasty right coronary artery (RCA) injection in right anterior oblique cranial view showing normally flowing vessel. The image simulates conventional left anterior oblique cranial projection for RCA.
Fig. 4.
Post angioplasty right coronary artery (RCA) injection in left anterior oblique view showing normally flowing vessel. The image simulates conventional right anterior oblique projection for RCA.
Discussion
Patients with dextrocardia may suffer from coronary heart disease as do people with normally positioned hearts. Because of unfamiliarity with the abnormal angiographic orientation of coronary anatomy and need for modified angiographic projections performing percutaneous coronary intervention in patients with dextrocardia presents several challenges to the interventional cardiologist. Few cases of percutaneous coronary intervention in patients with dextrocardia have been reported [2], [3], [4], [5].
In all cases right-left mirror-image inversion angiographic views along with counter-directional torquing of the catheter techniques were used. Even though this technique makes the procedure easy, unfamiliar coronary geometry makes the interpretation of the coronaries difficult when compared to orientation of coronaries in levocardia with which interventional cardiologists are familiar.
In the “double inversion technique” [1] described by us in 2005, the orientation of the coronaries simulates the coronaries in normally located heart and makes interpretation easy and avoids interpretive errors.
Transradial coronary angiography and angioplasty have emerged as safe, feasible, and effective alternatives with similar results to those of the transfemoral approach with negligible rate of major vascular complications [6], [7]. However there are only 3 reports on trans-radial intervention in patients with dextrocardia [8], [9], [10] out of which one patient underwent a procedure through left radial approach. Probably, left radial artery access is more suitable in view of mirror image aortic arch branching pattern where left radial artery joins left brachio-cephalic trunk and continues in alignment with ascending aorta. Since right subclavian artery arises as independent distal most branch of arch of aorta, with slight malalignment with the ascending aorta, it may be difficult to manipulate catheters in hooking the coronary ostia with regular catheters. By adopting the “double inversion technique” coronary intervention can be done in situs inversus with dextrocardia in a way much similar to interventions in normally located heart, thus alleviating apprehension.
Conclusion
Using the “double inversion technique” percutaneous coronary interventions can be done in patients with situs inversus and dextrocardia in a way much similar to interventions in normally located heart. Trans-radial approach is a feasible and safe alternative to femoral access even in patients with situs inversus with dextrocardia. However, left radial artery approach could be more suitable compared with left radial artery approach due to mirror image aortic arch branching pattern.
Footnotes
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2013.03.010.
Appendix A. Supplementary data
The following are the supplementary data to this article:
Aortic angiography in right anterior oblique view showing mirror image pattern right-sided aortic arch.
Right coronary artery (RCA) injection in right anterior oblique view 500showing critical disease in mid RCA. The anatomy simulates RCA injection in conventional left anterior oblique projection.
Post angioplasty right coronary artery (RCA) injection in right anterior oblique cranial view showing normally flowing vessel. The image simulates conventional left anterior oblique cranial projection for RCA.
Post angioplasty right coronary artery (RCA) injection in left anterior oblique view showing normally flowing vessel. The image simulates conventional right anterior oblique projection for RCA.
References
- 1.Goel P.K. Double-inversion technique for coronary angiography viewing in dextrocardia. Catheter Cardiovasc Interv. 2005;66:281–285. doi: 10.1002/ccd.20473. [DOI] [PubMed] [Google Scholar]
- 2.Raina T., Grech D., Cumberland D. Percutaneous coronary intervention in dextrocardia. Br J Cardiol. 2008;15:111–112. [Google Scholar]
- 3.Moreyra A.E., Saviano G.J., Kostis J.B. Percutaneous transluminal coronary angioplasty in situs inversus. Cathet Cardiovasc Diagn. 1987;13:114–116. doi: 10.1002/ccd.1810130208. [DOI] [PubMed] [Google Scholar]
- 4.Zambrano J., De la Hera A., De Marchena E. Mechanical reperfusion during acute myocardial infarction in a patient with dextrocardia. J Invasive Cardiol. 2006;18:E89–E92. [PubMed] [Google Scholar]
- 5.Jauhar R., Gianos E., Kashifuddin B., Roethel M., Kaplan B.M. Primary angioplasty in a patient with dextrocardia. J Interv Cardiol. 2005;18:127–130. doi: 10.1111/j.1540-8183.2005.00350.x. [DOI] [PubMed] [Google Scholar]
- 6.Agostoni P., Biondi-Zoccai G.G., de Benedictis M.L., Rigattieri S., Turri M., Anselmi M. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44:349–356. doi: 10.1016/j.jacc.2004.04.034. [DOI] [PubMed] [Google Scholar]
- 7.Jolly S.S., Yusuf S., Cairns J., Niemelä K., Xavier D., Widimsky P., Budaj A., Niemelä M., Valentin V., Lewis B.S., Avezum A., Steg P.G., Rao S.V., Gao P., Afzal R. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377:1409–1420. doi: 10.1016/S0140-6736(11)60404-2. [DOI] [PubMed] [Google Scholar]
- 8.Chen J.P. Repeat right transradial percutaneous coronary intervention in a patient with dextrocardia: the right approach to the right-sided heart. Catheter Cardiovasc Interv. 2007;69:223–226. doi: 10.1002/ccd.20915. [DOI] [PubMed] [Google Scholar]
- 9.Jang G.S., Kim H.S., Lee W.Y., Kim K.I., Kim J.S., Kim Y.M., Kim S.A., Jo S.H., Choi Y.J., Rhim C.Y. Left transradial coronary angiography in a patient with dextrocardia. Korean Circ J. 2010;40:601–603. doi: 10.4070/kcj.2010.40.11.601. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ishiguro H., Murohara T., Ikari Y. The feasibility of using Ikari left catheter via the right radial approach in a patient with dextrocardia for better guiding support. J Invasive Cardiol. 2011;23:E288–E290. [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Aortic angiography in right anterior oblique view showing mirror image pattern right-sided aortic arch.
Right coronary artery (RCA) injection in right anterior oblique view 500showing critical disease in mid RCA. The anatomy simulates RCA injection in conventional left anterior oblique projection.
Post angioplasty right coronary artery (RCA) injection in right anterior oblique cranial view showing normally flowing vessel. The image simulates conventional left anterior oblique cranial projection for RCA.
Post angioplasty right coronary artery (RCA) injection in left anterior oblique view showing normally flowing vessel. The image simulates conventional right anterior oblique projection for RCA.