PMC5863286_01
EKG shows the classical elements found in dextrocardia: right axis deviation of p wave with an inverted QRS axis of aVR. Signs of previous inferior MI: q waves in inferior leads.
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fig1
TIMI risk score was 2 (8% risk of event at 30 days). The EKG findings made us suspicious of a malposition syndrome (Figure 1).
Chest radiogram shows the right-sided heart (apex to the right) and gastric chamber to the right, which adds to the diagnosis of situs inversus.
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Sequence of percutaneous intervention with drug-eluting stent implantation in the proximal segment of the LAD. (a) Pre-PCI: shows a 70% stenosis at the proximal segment of LAD (stent in posistion, preimplantation). (b) Post-PCI: DES implantation.
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On May 25, 2015, percutaneous coronary intervention (PCI) was performed with an extra-backup support EBU 3.5, 6 French guiding catheter with the standard Judkins technique, using inverted horizontal axis angiographic views of the left coronary artery, to mimic a left anterior oblique (LAO) with a cranial view for the left anterior descending artery (LAD), an inverted view; that is, to the other side, a right anterior oblique (RAO) view was used, to proceed with a direct stenting of the proximal segment stenosis of the LAD, implanting a 2.5 x 16 mm drug-eluting (everolimus) stent (Promus Premier, Boston Scientific) successfully (Figures 3(a) and 3(b)).
(a, b) Sequence of stent implantation in the distal segment stenosis of the right coronary artery with previous balloon predilatation.
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fig4
Then, we proceeded to treat the right coronary artery 90% distal segment stenosis; for this, we used a right Judkins 3.5, 6F guiding catheter with horizontal mirror imaging, using a RAO view to mimic the LAO view; the anatomical right coronary artery was engaged easily using an opposite maneuver to the usual, with the tip of the catheter pointing leftward and rotated counterclockwise (instead of rotating clockwise), and then, we passed a Whisper 0.014 angioplasty guidewire and crossed the distal stenosis; predilatation was done with a 1.5 x 10 mm balloon (Apex, Boston Scientific), and then, a 2.5 x 12 mm zotarolimus-eluting stent (Resolute Integrity, Medtronic) was successfully implanted, obtaining excellent angiographic results and final TIMI grade 3 flow (Figures 4(a) and 4(b)).