Complex PCI in Dextrocardia
Presenter
Mark Staroselsky, D.O., Nassau University Medical Center, Mineola, NY, United States of America
Mark Staroselsky, D.O., Nassau University Medical Center, Mineola, NY, United States of America and Gaurav Rao, M.D., Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Westbury, NY
Title
Complex PCI in Dextrocardia
Introduction
The patient is a 79-year-old Spanish-speaking male initially presenting to cardiology for evaluation of anginal chest pain and dyspnea on exertion. His past medical history includes CAD with prior MI status post PCI with DES to LAD in 2015, non-insulin dependent type II diabetes mellitus, hypertension, mixed hyperlipidemia and dextrocardia. Patient underwent cardiac catheterization and ultimately required PCI to RCA with staged complex PCI to LAD with shockwave lithotripsy and calcium debulking. Adjustments to technique and angiographic displays were required due to dextrocardia.
Clinical Case
The patient underwent exercise and nuclear stress testing which demonstrated ischemia in the circumflex and LAD territories. He was referred for cardiac catheterization. Right sided ECG on day of cardiac catheterization demonstrated sinus rhythm with ST flattening anterolaterally. Cardiac catheterization was performed via right radial artery access and noted proximal LAD 80% calcified in-stent restenosis, proximal RCA 90% calcified stenosis, mid RCA 40% stenosis, and distal RCA 50% stenosis. Both the RCA and LAD were thought to be contributory to ischemia noted by nuclear imaging, however the RCA was felt to be culprit lesion for presenting unstable angina. The decision was made to intervene on the RCA given its critical nature, with subsequent staged intervention on LAD with calcium debulking. Intervention was performed on RCA with pre-dilation with semi-compliant balloon, followed by DES placement and IVUS guided post-dilatation. The patient was monitored in the hospital and brought back to the catheterization lab the following day for staged intervention on LAD via right femoral artery access. IVUS was performed and noted heavily eccentric and deep wall calcium within the lesion. The lesion was unable to be pre-dilated with a non-compliant balloon at high pressures, with appreciation of a “dog-bone” appearance due to heavy calcification. Calcium debulking therapy was successfully applied with shockwave lithotripsy and cutting balloon angioplasty. DES was deployed followed by post-dilatation with a non-compliant balloon. The patient tolerated the procedure well and was monitored in the hospital following PCI. He was started on clopidogrel in addition to his prior regimen of aspirin, high-intensity statin and beta-blocker therapy. Post-PCI ECG demonstrated resolution of ST/T wave abnormalities. He was discharged with outpatient cardiology follow up.
Discussion
This case demonstrated that coronary angiography and complex PCI can be readily performed in patients with dextrocardia. It is crucial to review patient history and prior imaging before intervention in order to be adequately prepared for possible anatomical variations. Cannulation of the coronary vessels can be achieved with the use of standard equipment, however technique adjustments may be needed in order to account for the mirror-imaged anatomy. To cannulate the RCA, the guide catheter requires counterclockwise rotation as opposed to clockwise. Similarly, cannulating the LM would require rotation of the guide catheter clockwise. To our knowledge, this is the first case of shockwave lithotripsy performed in a patient with dextrocardia. This case demonstrated that complex PCI and calcium debulking therapy with shockwave lithotripsy can be safely performed in patients with dextrocardia.