Percutaneous Coronary Angioplasty Through Right Radial Approach in a Patient with Mirror image Dextrocardia

To the Editor,

A 65-year-old male was admitted with an episode of retrosternal and right-sided chest pain suggestive of angina. He had been a smoker and diabetic in the past. Cardiac impulse was felt in the right 5th intercostal space lateral to the mid-clavicular line. Heart sounds were heard on the right side of the chest. Electrocardiogram (ECG) revealed inverted P waves in leads I and aVL and an upright P wave and R wave in aVR with reverse progression of R waves in the left precordial leads. X-ray of the chest showed right-sided heart with stomach shadow on the right side and liver on the left side. 2D echocardiography confirmed situs inversus with mirror image dextrocardia.

He was taken up for coronary angiography through the right radial approach. A 5F tiger catheter was used to cannulate coronary arteries. Double inversion technique was used. The left coronary artery was cannulated routinely which showed a long left main with normal left anterior descending coronary artery. Obtuse marginal (OM) of the left circumflex had a distal 80–90% narrowing. The right coronary was engaged in counter-clockwise rotation

A 6F EBU guide catheter was used for PCI of the OM coronary artery. The left coronary was cannulated easily without much manipulation through the right radial artery.

A 0.014″ × 190 cm RINATO PTCA guide wire was used to cross the OM lesion. The OM lesion was predilated with 2.0 × 10 mm balloon at 12 atm. Later a 2.25 mm × 18 mm stent was implanted in the distal OM at 12 atm.

Dextrocardia (DC) is an uncommon condition characterized by abnormal position of the heart on the right hemithorax. DC can be isolated or associated with complete right to left reversal of the abdominal organs with an incidence of 1 in 10,000 live births.^{1, 2} The incidence of coronary artery disease in DC is similar to that in the general population.^{3, 4}

Diagnostic cardiac catheterization was first reported in a DC patient in 1973. The first coronary angiography in dextrocardia was reported in 1974 in a patient who underwent left ventricular aneurysmectomy. In 1991 Blankenship reported a total of 10 cases with DC and coronary heart disease. The Judkins technique was used for coronary angiography in five cases the Sones technique in four cases and only one case required additional catheters.

Moreyra and co-workers performed the first coronary angioplasty in DC patients. Jauhar et al. performed the first PTCA of the circumflex coronary artery and Papadopoulos did the PTCA of the right coronary artery in patients with acute inferior wall myocardial infarction.

Fluoroscopy Guidelines in Dextrocardia Imaging

Right–left mirror images of traditional angiographic view angles facilitate recognition and navigation of the unusual arterial anatomies. Goel and others proposed the “double inversion” approach for imaging these patients ⁵ . They advocated the horizontal sweep reverse feature in the fluoroscopic equipment along with reversal of left and right anterior oblique angles. This method completely normalizes the location and course of the DC vasculature in interpreting coronary angiograms.

Challenges in PCI

Most of the case reports of PCI in DC have used either femoral or left radial for coronary artery cannulation; the right radial approach has not been commonly used earlier probably in view of some technical difficulties in entering aorta through the brachiocephalic trunk in DC with the right aortic arch. Initially, the femoral artery access is the usual approach in DC patients for cardiac catheterization and coronary angiography. In 2008, Macdonald et al. described the trans-radial approach for PCI in a stable angina patient for the first time. In our experience, the right trans-radial approach can be used safely in mirror-image DC without much technical difficulty.

As cardiologists we may get limited opportunity to perform cardiac catheterization in DC patients. This case report illustrates that by employing the “double inversion technique” with counterclockwise rotation of the routine coronary catheters, we can safely perform coronary angiography and interventions using the right radial artery approach.