Trans-Radial Percutaneous Coronary Intervention in Dextrocardia: Case Report and Review of Literature

Abstract

of 5 Fr JL 3.5 guide catheter and a 0.014" balanced middleweight (BMW) guide wire. Two overlapping drug-eluting stents (Xience Prime 2.5x28 mm and Promus Element 2.25x12 mm) were directly deployed at the site of the lesion in the middle segment of the LAD artery with good angiographic result (Figure 4). The patient experienced an uneventful post-PCI course and was discharged on the following day. He was free of angina on clinical follow-up. DiscussionDextrocardia refers to the position of the heart in the right side of the chest. It is a rare clinical phenomenon with a reported incidence of 1 in 5,000-30,000 [1]. In the absence of other structural heart disease, the life expectancy is usually normal. The association of coronary artery disease (CAD) in these patients is the same as in the general population [4]. Hence, even elderly patients with this rare anomaly have been subjected to successful percutaneous or surgical intervention of CAD, as reported in literatures [5,6]. The first cardiac catheterization in dextrocardia was reported in 1973 [7], the first coronary artertery bypass surgery in 1980 [8] and the first percutaneous intervention in dextrocardia performed in 1987 [9].Presentation of patients with dextrocardia with variant myocardial ischemia symptoms of right-sided chest pain has been previously noted [10][11][12]. The reason for this atypical presentation is unclear. Situs inversus has been previously shown to be associated with abnormal neural axis development [13] and this may lead to variant visceral pain presentation. Afferent fibers from the heart traveling along the sympathetic trunks of the neck and thorax may enter the higher thoracic levels (T1 to T4/5) from the right rather than the left side, thus associating with spinal ganglia and spinal cord segments receiving sensory impulses from the right side of the body. This may also explain previous reports of ischemic pain referral down the right shoulder and arm in these patients [7,14,15]. Pain localization from abdominal viscera is also discrepant and suggests that peripheral nerve route transposition occurs in about 50% of cases of situs inversus. Consequently, patients with dextrocardia may present with pain referred to either the left or the right side of the body [16].Moreyra et al. [9] who first reported a case of percutaneous transluminal coronary angioplasty in dextrocardia with situs inversus, found Judkins catheters unhelpful and advocated using multipurpose catheters because their flexible tips allowed for easy manipulation into the coronary ostia. It has since been suggested that the suitability of diagnostic and interventional guide catheters can be predicted by the aortic arch position [17][18][19]. In our experience, however, even in the presence of right-sided aortic arch, the left Judkins catheter can be used to cannulate the right-sided morphologically left coronary artery. Similarly, the right Judkins catheter manipulated to the mirror of its usual position can cannulate the left-sided morphological RCA. Notably, cathe...

Triple vessel percutaneous coronary intervention in a patient with situs inversus dextrocardia using a transradial approach

“…Transradial PCI in situs inversus dextrocardia has been reported for STEMI 7 , double 13 and single 14 vessel disease using extra support (ECR), Judkins, AL2, guide catheters respectively. Transradial rotablation has also been described in situs inversus dextrocardia with STEMI 15 .…”