Percutaneous Transluminal Coronary Angioplasty in a Patient with Congenital Diaphragmatic Bochdalek Hernia

Abstract

Abs tractHerniations through the foramen of Bochdalek are very rare diaphragmatic hernias in adults. Even in infants, respiratory distress syndrome manifests as a complication of a disease, it may be asymptomatic until late in life. Although the presenceof atherosclerotic process do not differ from normal, angiographic characteristics of these vessels, such as the orifice configuration, exit angulation, the route of the artery and the location of the stenotic lesions are much more different. We report an extremely rare case of percutaneous treatment of a coronary stenosis in a patient whose heart was displaced to the right side of the chest due to congenital diaphragmatic Bochdalek hernia. ( CaseReportA seventy-year-old male with a history of uncontrolled hypertension and dyslipidemia was admitted to our hospital with typical anginal pain at rest. At the time of admission, his blood pressure and pulse rate were 150/90 mmHg and 88 beats per minute, respectively. Physical examination showed a diminished breath sounds at auscultation. The electrocardiogram on admission revealed reduction in R wave voltage across the chest leads. Telecardiography showed sliding of the heart to the right side of the thorax and presence of bowels on the left side of the thorax (Figure 1). Initial diagnosis was acute coronary syndrome and laboratory evaluation showed normal cardiac enzymes and high troponin levels. Gastroenterology consultation was assessed and congenital diaphragmatic hernia was diagnosed after evaluation. Due to unstable cardiovascular condition of the patient, coronary angiogram was performed. The transfemoral approach was used but the left coronary arteries could not be cannulated with a standard left Judkins 6 F catheter. The positions of the aorta and coronary ostium were changed due to the displacement of the heart as a consequence of the hernia. Coronary ostiums were more vertical and the distance and the angle between the contralateral part of the aorta and coronary ostium were different from the normal coronary anatomical positions. We could not cannulate the coronary arteries in spite of repeated attempts using different maneuvers with the Judkins catheter which had a short and bent tip. For easy back-up and good engagement to the coronary artery ostium, extra back up (EBU) diagnostic catheter was chosen. Severe lesions were seen in the proximal and mid segments of the left anterior descending artery (LAD) (Figure 2). The right and circumflex arteries were normal.