Percutaneous drug-eluting stent implantation in dextrocardia: case report

Although situs inversus with dextrocardia is a rare clinical phenomenon, the association with coronary artery disease(CAD) is at the same frequency as in the general population.^1,2 Few cases of dextrocardia complicated with CAD was reported before. The feasibility and prognosis of percutaneous coronary intervention (PCI) in such case still remains unclear because of the uncommon anatomical abnormality, especially in the drug-eluting stent (DES) era. Here we report a female case with dextrocardia and CAD was successfully treated by DES implantation.

A 66-year-old Chinese woman was admitted to our hospital on December 16, 2005 after her first attack of acute myocardial infarction 14 days before. The patient herself reported a medical history of dextrocardia and well controlled hypertension with medications. The electrocardiograph (ECG) obtained after admission with reversed limb leads and right-sided precordial leads revealed poor R-wave progression and T wave changes in the anterior leads (V1－V6, Fig. 1). Serum cardiac enzymes, including creatine kinase- MB, troponin-I, were normal at admission. The serum triglyceride level was mildly elevated (2.94 mmol/L) with normal cholesterol concentration. No other abnormalities were detected in blood test with regard to glucose, renal function, etc. Ultrasound cardiography (UCG) study revealed mild mitral regurgitation, the left ventricular ejection fraction was 0.65 evaluated by modified Simpson's method and no other congenital disease was complicated. A right-sided heart was confirmed under chest X-ray examination (Fig. 2).

Aspirin (100 mg/d) and clopidegrel (75 mg/d) were described after admission and 5 days later coronary angiogram was performed by Jundkins left (JL 4.0) and right (JR 4.0) diagnostic catheter (Cordis, USA) via right femoral access. At the projection of left anterior oblique (LAO) 22˚ and caudal 27˚, a significant stenosis (73.1% in quantitative coronary angiography (QCA)) in the proximal segment of left anterior descending (LAD) coronary artery was clearly identified (Fig. 3). Left a normal left ventricular ejection function (LVEF=70.9%) and right-sided ascending aorta (Fig. 4). After intravenous injection of unfractionated heparin 5000 U, a vetriculogram revealed JL 4.0 guiding catheter (Cordis, USA) was successfully engaged to the left coronary artery. A 0.3556 mm (0.014”) guide-wire (ATW, Cordis, USA) crossed the lesion and after pre-dilated with a 2.0 mm (diameter) monorail balloon catheter (20 mm in length, Turomo, Japan), a Firebird sirolimus-eluting stent (3.0 mm in diameter by 33 mm in length, Microport, Shanghai, China) was implanted successfully under 16 atmosphere pressure and 10-second duration. TIMI 3 flow and minimal residual stenosis of 16.3% (by QCA) was achieved finally without procedural complications (Fig. 5). The patient was discharged 2 days after and remained free of angina symptoms at 4-month clinical follow-up. Dual antiplatelet therapy with aspirin and clopidegrel was suggested for at least 6 months on this patient.

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Fig. 3. Coronary angiography (LAO caudal) showing a significant lesion in LAD (73.1% in diameter stenosis in QCA)
Fig. 4. LAO left ventriculogram indicating a normal left ventricular systolic function (LVEF=70.9%) and a right sided ascending aorta.
Fig. 5. Coronary angiography (LAO caudal) after stenting showing TIMI 3 flow and minimal residual stenosis (16.3% in QCA).

DISCUSSION

Dextrocardia, usually termed as the location of the heart mainly in the right chest and with the cardiac long axis directing to the right and inferiorly,³ occurs rarely with a frequency of 1/10 000 in general population.⁴ Garg et al² reported that only 7% of patients with situs solitus dextrocardia had normal intracardiac anatomy, and diagnosis of cardiac malformation could be achieved by transthoracic echocardiography. In the currently reported patient, the echocardiography revealed no structural abnormalities complicated and a mild hypokinetic movement in the anterior region of the left ventricular wall.

Patients with dextrocardia suffer from CAD as those with normal positioned heart.⁴ The most important modifications in performing coronary angiogram in such patients are opposite-direction catheter rotations and mirror-image angiographic angles, i.e. anticlockwise rotation needed in the ascending aorta for right coronary artery and reversing the required right anterior oblique (RAO)/LAO angles, keeping the cranial/caudal tilts the same.^5-7 A double-inversion technique was reported to normalize all angiographic pictures to the standard conventional pictures as seen in a normally located heart, i.e. a combination of a right-left reversal of the image on the monitor using the “horizontal sweep reverse” function during acquisition and a reversed RAO/LAO angle selection.⁸ This technique should be useful to identify the coronary anatomy in some complex cases. Limited data were available regarding to percutaneous transluminal coronary angioplasty (PTCA) for patients with CAD. Successful PTCA was reported for the first time in 1987.⁹ Yamazaki et al¹⁰ concluded that by visualizing the procedure as a mirror image and choosing a guide catheter that permitted good engagement, PTCA was feasible for patient with dextrocardia and CAD. To our best knowledge, DES implantation for patients with dextrocardia was very limited in literature. In the currently reported case, a China-made sirolimus- eluting stent (Firebird, Microport, China) was implanted successfully after balloon pre-dilatation for the lesion. The patient was discharged two days after the procedure without any in-hospital complications and continued on dual anti-platelet medications (aspirin and clopidegrel) and keeps symptoms free at 4-month clinical follow-up, which indicates DES implantation is safe and efficacy in treating dextrocardia patient with CAD.

In conclusion, a mirror image will help visualize the morphology of the coronary artery during the procedure, a well engaged guiding catheter is essential and rotation in an opposite direction to that normally used could help engagement of guiding catheter. Drug-eluting stent could be implanted in patient with dextrocardia and CAD successfully and exerts the same good clinical effect as treating patients with CAD and normal sided-heart.¹¹

REFERENCES

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