Mirror magic: How to handle a patient with dextrocardia

Anida Gjata (Trier)1, N. Werner (Trier)1, J. Leick (Trier)1

1Krankenhaus der Barmherzigen Brüder Trier Innere Medizin III Trier, Deutschland


Dextrocardia with situs inversus totalis, is a congenital heart condition in which the orientation of the heart in the thorax is inverse with the heart to be located on the right side of the chest and the cardiac chambers to be a mirror image of the normal anatomy. This is a very rare condition with an incidence of 0,008 -0,01%. Diagnosis and treatment of CAD or ACS can be challenging due to the anatomical asymmetry.

A 73 year old woman, with a history of situs inversus totalis, arterial hypertension, hyperlipidemia and diabetes mellitus presents electively in our center. Due to exertional dyspnea, a myocardial scan was performed where a long-stretch calcified coronary sclerosis was identified. She was referred to angiography before an upcoming long-distance trip. The diagnostic findings were consistent with dextrocardia. The angiography revealed a triple vessel disease with high grade stenosis of the RCA. The patient declined the option of a surgical revascularization. Revascularization with pre-dilatation and implantation of three drug-eluting stents was successfully performed. The patient was discharged a day after the percutaneous coronary intervention (PCI). A control angiography was performed 4 months after and showed a good result after complex PCI. The other stenoses were found to be hemodynamically irrelevant based on invasive functional measurement. At this time the patient was symptom free.
Fig. 1: Fig. 2: Coronary angiography of the RCA before PCI Coronary angiography of the RCA after PCI

Dextrocardia with situs inversus totalis is a rare condition. The literature, especially regarding PCI, is due to the low incidence limited to a few case reports. In the absence of special guidelines, we emphasize the teaching role of every experience brought through case presenting. In the literature there are a couple of modifications recommended for engagement and obtaining the best images. The preferred access is the femoral access. There are also a few cases of successful PCI via radial access. We tried at first to engage through a transradial access and switched to transfemoral as the above failed. Finding the right catheter might also be an issue. We recommend starting with standard catheters to get an impression of the anatomy and position of the coronary arteries. On this basis, we recommend the selection of a suitable interventional catheter. In addition to the interventional catheter, the use of a mother-in-child catheter may be useful. One of the main problems can be choosing the right angulation angle. Here we recommend proceeding in the opposite direction to normal coronary angiography. We inverted the oblique views without changing the cranio-caudal angulation. It must be taken in consideration that the views obtained are mirror reversed. A horizontal sweep reverse can be helpful in this case.

Although Dextrocardia is a rare heart condition, the frequency of CAD is the same in this group of patients. Except for a few modifications in the angulation, basically no great alterations are needed. We recommend: while keeping the anatomy in mind, keep it smart, simple and safe.

Keywords: dextrocardia, situs inversus, angiography, PCI, CAD

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