Correspondence Address: Dr. Munish Dev Department of Cardiology, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra - 176 001, Himachal Pradesh India
Source of Support: None, Conflict of Interest: None
Dextrocardia is a rare condition with mirror-image position of the heart. Given the rarity of this condition, percutaneous coronary intervention in dextrocardia can be technically challenging. A modification in catheter manipulation and image acquisition technique is required for a successful procedure. We report a case of non-ST elevation myocardial infarction in a 55-year-old male patient with dextrocardia, managed successfully with coronary angioplasty of the right coronary artery through the left transradial route.
How to cite this article: Rana N, Dev M, Sharma A. Percutaneous transluminal coronary angioplasty in a patient with dextrocardia using left transradial approach. Heart India 2019;7:172-4
How to cite this URL: Rana N, Dev M, Sharma A. Percutaneous transluminal coronary angioplasty in a patient with dextrocardia using left transradial approach. Heart India [serial online] 2019 [cited 2022 Jan 21];7:172-4. Available from: https://www.heartindia.net/text.asp?2019/7/4/172/272659
Dextrocardia is a rare congenital condition affecting 0.01% of newborns and is characterized by malpositioning of the cardiac apex on the right side. It may be isolated or associated with situs inversus. The incidence of coronary artery disease (CAD) in dextrocardia is same as in general population., However, percutaneous coronary intervention (PCI) in these patients is challenging to an interventional cardiologist due to abnormal orientation of coronary anatomy and need for modified views. We describe a patient with dextrocardia presenting with acute coronary syndrome, managed with percutaneous coronary angioplasty through the left transradial route.
A 55-year-old male patient with a history of hypertension presented with acute onset chest pain for the past 8 h in the emergency department of our institute. On general physical examination, pulse rate was 60 bpm and blood pressure was 90/60 mmHg. On cardiovascular examination, apex was found on the right side with normal S1 and S2 on auscultation. Electrocardiography (ECG) of the left side was consistent with dextrocardia (inverted P-waves in leads I and aVL, upright P-wave with prominent R-wave in aVR, and prominent S-wave in the left precordial leads with no evidence of QRS transition in the precordial leads) and showed T-wave inversion in leads II, III, and aVF [Figure 1]. Troponin I and creatine kinase–myocardial band were raised. Chest radiograph showed dextrocardia with normal cardiac size. Stomach bubble was seen on the right side [Figure 2]. Ultrasound abdomen (done on the 2nd day of admission) showed inversion of abdominal viscera with the liver and gall bladder on the left side and the spleen on the right side confirming the diagnosis of dextrocardia with situs inversus.
Figure 1: Electrocardiography of the patient at the time of admission showing inverted P-wave in leads I and aVL, upright P-wave with prominent R-wave in aVR, and prominent S-wave in the left precordial leads suggestive of dextrocardia. Furthermore, note the presence of T-wave inversion in leads II, III, and aVF indicating inferior wall ischemia
The patient was taken up for coronary angiography through the left transradial route. Selective coronary angiography with 5F tiger catheter was done using mirror-image angiographic angles. There was difficulty in hooking right coronary artery (RCA), and it was hooked with counterclockwise rotation. Right coronary angiography showed around 90% stenosis in the mid-part of RCA [[Figure 3]a, [Figure 3]b and Video 1]. The left anterior descending (LAD) artery showed significant stenosis (~70% stenosis) just after the first septal branch. Left circumflex artery showed ~60%–70% stenosis in the obtuse marginal branch [[Figure 3]c and Video 2]. Percutaneous angioplasty of RCA was planned through transradial route. Judkins right (JR) 3.5, 6F guiding catheter was used to hook RCA. There was a difficulty in hooking RCA, and it was hooked with anticlockwise rotation of catheter. Fielder FC wire (Asahi Intecc, Japan) was used to cross the lesion. The second wire (Balance Middleweight, Abbott Vascular) was used for catheter support. Predilatation with semi-compliant balloon of size 2.5 mm × 10 mm (Mozec, Cordis, US) was done [Video 3], followed by deployment of sirolimus-eluting stent (BioMime, Meril) size 3.5 mm × 13 mm. TIMI-III flow was achieved through and beyond stent with no residual stenosis [[Figure 3]d and Video 4]. Postprocedure patient's chest pain was relieved, and ECG showed normalization of T-wave in the inferior leads [Figure 4]. Postprocedure hospital course was uneventful, and the patient was discharged after 2 days with plan for staged revascularization in the future (PCI in LAD).
Figure 3: Preprocedure coronary angiogram showing ~90% stenosis in the mid-portion of the right coronary artery (white arrow in a and b). Stenosis was also seen in the left anterior descending artery (~70%) just after origin of the first septal branch (black arrow in c) and obtuse marginal branch (60%–70%) of the left circumflex artery (white arrow in c). Angioplasty of the right coronary artery lesion was performed, and postprocedure angiogram showed TIMI-III flow in the right coronary artery with no residual stenosis (d)
The incidence of CAD in patients with dextrocardia is similar to that of general population. Literature on the diagnosis and management of ischemic heart disease in dextrocardia is scanty. Cardiac catheterization in a patient with dextrocardia was first reported in 1973. Given the rarity of this condition, angiography in these patients can be technically challenging. Initially, the use of multipurpose catheters was advocated to perform angiography in dextrocardia. However, lately, standard coronary catheters have been employed successfully.,
Few technical modifications are required while performing angiography in patients with dextrocardia. The first modification is manipulation of catheters in the direction opposite to that used in normal patients. For example, instead of clockwise, a counterclockwise rotation is required to hook RCA. The second modification involves modification of angiographic angles. Mirror-image angiographic angles are employed (that is changing right and left oblique angles), while keeping the cranial or caudal tilt same., However, reversal of angiographic angles leads to a reverse set of images which pose difficulty in angiographic interpretation. To overcome this problem, Goel et al. have suggested double-inversion technique  which involves right/left image reversal using “horizontal sweep reverse” button on the machine and reversal of angiographic angle. As a result, final images obtained after double inversion resemble the normal angiographic images in patients with levocardia, thereby leading to quicker and easier interpretation of images in cases of dextrocardia.
PCIs in dextrocardia have been performed through transfemoral ,, and transradial routes.,,,, In recent years, transradial approach for coronary interventions has gained popularity as it is more comfortable to the patient with comparable results to transfemoral approach. Both right ,, and left transradial  approaches have been described in patients with dextrocardia. Although routinely right radial approach is used for coronary angiography in our institute, we used a left radial approach in this case, in view of mirror-image branching pattern. We used standard coronary catheters with opposite direction catheter rotation and mirror-image angiographic angles. RCA was hooked using JR catheter with counterclockwise rotation, and right anterior oblique 60° angle was used for image acquisition.
To conclude, while performing angiographic procedures in patients with dextrocardia, standard catheters can be used with modification in catheter rotation technique and angiographic angles. The interventional cardiologist should be familiar with these techniques for successful PCI in these patients.
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:E288-90.