Abstract: Patients with dextrocardia present unique challenges in the catheterization laboratory. Variable coronary artery anatomy impacts percutaneous access, catheter selection and manipulation, and image acquisition. This is a review of all published reports of radial artery access for diagnostic and/or therapeutic coronary interventions in patients with dextrocardia. We conclude that the radial approach is safe and effective in these patients and should be used without hesitation. In addition, interventionalists should consider use of multipurpose catheters and possess an understanding of how mirror-image fluoroscopy impacts catheter manipulation. Furthermore, we propose a stepwise approach to arterial access, fluoroscopy, and catheter selection for operator reference while treating dextrocardia patients.
J INVASIVE CARDIOL 2019;31(5):E83-E88.
Key words: dextrocardia, invasive angiography, radial artery access
Dextrocardia (DC) is a rare condition that occurs in 1/10,000 live births, and the incidence of coronary atherosclerosis in these patients is thought to be similar to that of the general population.1 When invasive coronary angiography (ICA) is indicated, the anatomical variation in DC can complicate engagement of the coronary ostia, and the choice of percutaneous access must be carefully considered.
Coronary arteriography via the transfemoral approach was first described by Ricketts and Abrams in 1962, yet ICA in DC was not reported until 1973.1,2 Campeau published his initial experience using the radial artery for percutaneous access in ICA in 1989, but the transradial approach was first described in a patient with DC 18 years later.3,4
We describe 2 cases of patients with DC who underwent ICA via the right radial approach: an elderly male presenting with acute coronary syndrome (ACS) and a female with progressive stable angina. To complement our experience, we provide a comprehensive review of all published reports of transradial access for both diagnostic and therapeutic coronary interventions in patients with DC over the past decade. Furthermore, we propose a stepwise approach to arterial access, fluoroscopy, and catheter selection in DC patients for operator reference (Figure 1).
Case Example #1
A 77-year-old man with a history of type 1 diabetes mellitus, hypertension, and DC presented to a community hospital after experiencing 5-10 minutes of substernal chest pain that woke him from sleep. At presentation, he was asymptomatic, but bradycardic with a heart rate of 47 bpm, and hypertensive with a blood pressure of 167/74 mm Hg. Troponin I was elevated at 0.345 ng/mL (0-0.056 ng/mL). He was loaded with 325 mg of aspirin and 180 mg of ticagrelor and transferred for ICA.
Upon arrival to our institution’s catheterization laboratory, the patient was prepped for ICA, and right radial arterial access was obtained with a 6 Fr sheath. Angiography of the left main coronary artery and its branches was performed using a 5 Fr Jacky catheter (Terumo), obtaining mirror images of the standard fluoroscopic views. Angiography of the right coronary artery (RCA) was performed using a 6 Fr Judkins Right (JR) 4.0 catheter. Angiographic findings included diffuse, mild, three-vessel coronary atherosclerosis without evidence of acute plaque rupture (Figures 2A and 2B). The patient was admitted to the general cardiology service, where a transthoracic echocardiogram revealed a normal left ventricular ejection fraction and no wall-motion abnormalities. He was discharged on optimal medical therapy for coronary artery disease.
Case Example #2
A 63-year-old woman with type 2 diabetes mellitus, hypertension, hyperlipidemia, and DC was evaluated in our outpatient clinic for stable angina associated with activities such as stair-climbing and vacuuming. A treadmill exercise nuclear stress test was ordered. The resting electrocardiogram was abnormal for T-wave inversions across the anterolateral precordium. Recurrence of angina limited her to only 2 minutes of exercise (4.6 metabolic equivalents), but there was no scintigraphic evidence of myocardial ischemia. Due to her poor functional capacity, abnormal baseline electrocardiogram, and concerning symptoms, she was scheduled for elective ICA.
In the catheterization laboratory, arterial access was obtained via the right radial artery using a 5 Fr sheath. Under fluoroscopic guidance, ICA of the right and left coronary arteries was performed using a 5 Fr Jacky catheter and mirror images of the standard views. There was diffuse, mild atherosclerosis in the left anterior descending and circumflex arteries, but no significant coronary stenosis was identified (Figures 3A and 3B). The patient was discharged with medical therapies for atherosclerotic coronary disease.
ICA in DC was first reported at the Mayo Clinic in 1973, and since then, several case reports have detailed operator experiences with diagnostic angiography and percutaneous coronary intervention (PCI) in these patients. Authors often discuss catheter selection and manipulation, image acquisition strategies, and stent deployment. Cardiologists can use these accounts to guide clinical and technical decisions when encountering patients with similar anatomical variation. For instance, PCI in ST-segment elevation myocardial infarction was reported by Moreyru et al in 1982, transradial access by Chen in 2007, and transradial PCI using rotablation by Showkathali and Davies nearly 30 years after the first PCI – all firsts in patients with DC.4-6
The transradial approach for ICA is associated with similar clinical success rates and fewer procedural complications compared with transfemoral access.7,8 In the United States, the radial artery remains an under-utilized vascular access point for ICA in both elective and non-elective cases.9 There may be particular reluctance to utilize this approach in patients with DC due to perceived difficulty navigating the acute angle between the subclavian and/or innominate artery with the aortic arch as well as engaging the “reversed” coronary ostia.
In a review of PubMed, we identified 18 case reports of ICA using transradial access in DC (Table 1). Nine of these cases were in the setting of ACS. The operators accessed the right radial artery in all but 1 case, and there were no complications among all accounts. Sixteen cases described successful PCI, 3 patients underwent intervention to >1 coronary artery, and there was 1 report of rotational atherectomy. A variety of guide catheters were used successfully for intervention; however on a few occasions the conventional Judkins and Amplatz Left guide catheters proved to be poor choices.
In an effort to educate other operators, authors have reported on catheter selection and manipulation strategies. Although early attestations recommended against the use of Judkins catheters, several cases published subsequently have documented success using these traditional, preformed catheters.10-13 In contrast, the use of multipurpose catheters has been shown to be difficult.14-16 In our first case, we had difficulty with the Jacky catheter, but successfully engaged the right coronary ostia with a JR catheter. The Jacky catheter was effective at engaging both ostia in our second case. Regardless of catheter selection, it is important to recognize that the coronary anatomy is reversed in patients with DC; therefore, catheter manipulation must also be in the opposite direction (ie, the JR catheter is rotated counter-clockwise to engage the left anatomical RCA).
Image acquisition is another important consideration for interventionalists, as standard fluoroscopic views depict the coronary tree in an abnormal orientation. All but two authors performed ICA by creating a “mirror image” rather than taking advantage of fluoroscopy processing capabilities to invert the image so that it appears “normal.” The latter technique utilizes the “horizontal sweep reverse” feature of fluoroscopy equipment and has been described previously.17 Mirror-image views are obtained by reversing transverse angulations while maintaining illuminator position in the same sagittal plane (ie, the right anterior oblique caudal view elicits a mirror image of the left anterior oblique caudal view). We obtained mirror images, preserving the true orientation of the coronary arteries and cardiac silhouette. This appears consistent with the practices of most operators.10-13,18-20
In summary, ICA in the setting of DC deserves careful consideration of catheter choice, image projection schemes, and if needed, the interventional approach. Radial artery access is safe and effective and may be preferred by all experienced operators who use this approach routinely.
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8. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377:1409-1420.
9. Masoudi FA, Ponirakis A, de Lemos JA, et al. Executive summary: trends in U.S. cardiovascular care: 2016 report from 4 ACC National Cardiovascular Data Registries. J Am Coll Cardiol. 2017;69:1424-1426.
10. Ishiguro H, Murohara T, Ikari Y. The feasibility of using Ikari left catheter via the right radial approach in a patient with dextrocardia for better guiding support. J Invasive Cardiol. 2011;23:E288-E290.
11. He J, Sun Y, Zhang X, et al. Emergent percutaneous coronary intervention for acute myocardial infarction in patients with mirror dextrocardia: case reports and brief review. Cardiovasc Diagn Ther. 2016;6:267-273.
12. Michas G, Kaplanis I, Stougiannos P, et al. Successful transradial coronary angioplasty in a patient with dextrocardia and acute myocardial infarction. Hellenic J Cardiol. 2016;57:463-466.
13. El-Hosieny A. Trans-radial percutaneous coronary intervention in dextrocardia: case report and review of literature. J Cardiol Curr Res. 2014;1:1-4.
14. Potdar A, Sapkal G, Sharma S. Triple vessel percutaneous coronary intervention in a patient with situs inversus dextrocardia using a transradial approach. Indian Heart J. 2016;68:S32-S35.
15. Menozzi M, Guiducci V, Pignatelli G, Giacometti P, Manari A. Coronary stenting using the radial approach in two women with situs viscerum inversus and acute myocardial infarction. Cardiovasc Revasc Med. 2012;13:128-132.
16. Sinha RP, Agarwal D, Sarang AM, Thakkar AS. Successful transradial percutaneous coronary intervention in a patient with dextrocardia and situs inversus. J Clin Diagn Res. 2015;9:OD04-6.
17. Goel PK. Double-inversion technique for coronary angiography viewing in dextrocardia. Catheter Cardiovasc Interv. 2005;66:281-285.
18. Zhao ZW, Lin CG, Chen LL. Repeat right transradial intervention in 9 days in a patient with dextrocardia and situs inversus. Tex Heart Inst J. 2010;37:734-735.
19. Macdonald JE, Gardiner R, Chauhan A. Coronary angioplasty via the radial approach in an individual with dextrocardia. Int J Cardiol. 2008;131:e10-e11.
20. Jang GS, Kim HS, Lee WY, et al. Left transradial coronary angiography in a patient with dextrocardia. Korean Circ J. 2010;40:601-603.
From the Division of Cardiovascular Medicine, Department of Internal Medicine, Linda and Jack Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript submitted December 31, 2018 and accepted January 14, 2019.
Address for correspondence: Gregory J. Sinner, MD, Division of Cardiovascular Medicine, 900 South Limestone Avenue, CTW Building RM 320, Lexington, KY 40536-0200. Email: email@example.com