Successful Rotational Atherectomy and Stenting in a Situs Inversus Patient

Situs inversus with dextrocardia occurs rarely, with an estimated incidence of 1:10000.1 Dextrocardic patients usually have structurally normal hearts2 and may suffer from coronary atherosclerosis as do people with normally positioned hearts.3,4 Few cases of percutaneous transluminal coronary angioplasty (PTCA) in dextrocardic patients have been reported.3,5,6 To our knowledge, this is the first report of the successful ad hoc rota-stenting of a complex coronary lesion in a patient with situs inversus and dextrocardia. Case Report. A 66-year-old female with situs inversus and dextrocardia was referred to our center for angiographic diagnosis and management of progressive disabling angina. Exercise myocardial perfusion scan revealed severe ischemia in the inferior wall of the left ventricle. She also had diabetes mellitus, hypertension and hypercholesterolemia. Physical examination was unremarkable except for findings consistent with situs inversus. Normal heart sound and apical impulses were present in the right chest. A left-side liver edge was also palpated. Chest x-ray revealed dextrocardia with a right-sided aortic knob as well as gastric bubble. The electrocardiogram, with leads reversed appropriately for dextrocardia, showed left ventricular hypertrophy and non-specific ST changes. Echocardiography disclosed normal left ventricular function without other congenital abnormalities. Cardiac catheterization was performed via the left common femoral artery access using mirror image views. The ostium of the left main coronary artery was easily cannulated with simple catheter advancement using a Judkins left, 6 French (Fr), 4 cm diagnostic catheter in an anteroposterior (AP) position. The selective coronary angiogram of the left coronary artery revealed a 35% tubular stenosis in the mid left anterior descending (LAD) artery and a normal left circumflex (LCX) artery (Figure 1). A fluoroscopic view in the right anterior oblique (RAO) 30° position and counterclockwise rotation of a 6 Fr Judkins right 4 cm diagnostic catheter were used to engage the ostium of the right coronary artery (RCA). The RCA was a 3.5 mm dominant vessel with two 90% heavily calcified stenoses at the mid and mid-distal segments (Figure 2). A normal left ventricular end diastolic pressure of 12 mmHg was measured prior to ventriculography. The 35° left anterior oblique (LAO) ventriculogram showed no regional wall motion abnormality with a calculated ejection fraction of 57%. An ad hoc percutaneous transluminal coronary intervention was performed to the RCA. High-speed rotational atherectomy was employed to debulk the long calcified lesion to facilitate stenting. The ostium of the RCA was easily engaged by gentle counterclockwise rotation and withdrawal of a 7 Fr Judkins right 4 cm side-hole guiding catheter in RAO view. The complex lesion was crossed with a 0.014 x 0.009´´, Extra-support Rota-wire. (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) Rotational atherectomy was performed using a 1.75 mm Rotablator burr (Figure 3A). Three passes were made with the rotablator set at 165,000 rpm. A good-sized channel resulted without dissection. A 3.5 x 20 mm Tsunami stent (Terumo Medical Corporation, Somerset, New Jersey) was then deployed at the mid-distal lesion. Overlapping the previous stent, a 3.5 x 24 mm AVE S670 stent (Medtronic AVE, Santa Rosa, California) was deployed at the mid lesion (Figure 3B). Final angiography revealed 0% residual stenosis and no dissection (Figure 4). The patient made an uneventful recovery and was discharged home with clopidogrel for 4 weeks. She was free of angina on clinical follow-up for more than 6 months. Discussion. Situs inversus with dextrocardia is a rare congenital anomaly of development characterized by a mirror image position of the heart and abdominal viscera.1 We describe an elderly lady with situs inversus and disabling angina due to complex coronary stenoses. Coronary angiography and ad hoc rota-stenting were accomplished with a few subtle modifications of standard techniques. The experience with coronary angiography in dextrocardic patients had been previously reported.3,7–10 Since our dextrocardic patient has a mirror image abnormality, the positions of the coronary ostia relative to the sinuses and to the aortic arch were mirror images of the normal orientation. Cardiac catheterization was easily performed from the left femoral artery in our case. Mirror image angiographic angles were also found to be very helpful for catheter manipulations and image acquisition. An opposite-direction catheter rotation is another important modification in performing coronary angiography in this case. Counterclockwise rotation was used to engage the ostium of the RCA in our patient rather than the standard clockwise catheter rotation. In contrast to Moreyra’s finding that the standard coronary catheters are difficult to use because of the mirror image of the coronary arteries,11 we did not encounter any problem using the Judkin’s catheters to engage the coronary ostia. Similar use of conventional coronary catheters in patients with dextrocardia has been described in the literature.3,6,7 Since dextrocardia with situs inversus is a mirror image abnormality, the relative relation of the coronary ostia to the aortic arch is the same. The preformed curves of the conventional coronary catheters maintain their standard anatomic relationships to the coronary ostia and the various fulcrums in the aortic arch. Successful standard PTCA in patients with dextrocardia have been reported.6,11–13 Lewis et al.14 reported the successful directional coronary atherectomy of an eccentric lesion. This case represents the first report of rotational atherectomy and stenting of complex coronary lesions in a situs inversus patient. Standard balloon angioplasty of a long calcified lesion may cause significant dissection and “unzip” the coronary artery in extreme cases. Rotational atherectomy debulks the calcified lesion and modifies the compliance of the vessel to facilitate stenting.15 Current data suggest that rota stenting provides better acute and long-term outcomes in coronary lesions of complex morphology.16 This report validates that modified techniques with opposite-direction catheter rotations and mirror image views permit uncomplicated coronary angiography and device intervention in dextrocardic patients. Furthermore, rotational atherectomy and stenting are applicable for the intervention of complex coronary lesion in a situs inversus patient.

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