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Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12240-2
10.1016/j.heliyon.2024.e36209
e36209
Case Report
Coronary angiography in dextrocardia with situs inversus and acute myocardial infarction: A case report and literature review
Lu Lin a
Li Dai-Xu luciferldx@163.com
b⁎
a Department of Cardiology, The Third Hospital of Jinan, Jinan, 250132, Shandong Province, China
b Department of Cardiology, Jinan Fourth People's Hospital, Jinan, 250031, Shandong Province, China
⁎ Corresponding author. luciferldx@163.com
14 8 2024
30 8 2024
14 8 2024
10 16 e3620911 2 2024
29 7 2024
12 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
We present the case of a 74-year-old man with dextrocardia and situs inversus who presented with non-ST-elevation acute myocardial infarction. The patient underwent successful coronary angiography without requiring percutaneous coronary intervention or coronary artery bypass grafting. We discuss the patient’s clinical characteristics, electrocardiography findings, diagnosis, and treatment, and review the relevant literature.

Keywords

Dextrocardia
Situs inversus
Electrocardiography
Coronary angiography
Acute myocardial infarction
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pmc1 Introduction

Dextrocardia with situs inversus totalis is a rare congenital abnormality. In this condition, the heart is located on the right side of the chest but functions normally despite its unusual position. The incidence of dextrocardia with situs inversus totalis is approximately one in every 10,000 births.[1] The risk of coronary artery disease is comparable to that of the general population. However, the unique anatomy of dextrocardia poses challenges in the diagnosis and treatment of myocardial infarction.[2]

2 Case report

A 74-year-old man presented to the emergency department with chest tightness lasting 1 h, which was relieved by nitroglycerin administration. His medical history included dextrocardia, alcohol abuse, smoking, impaired fasting plasma glucose levels, and hyperlipidaemia. Initial vital signs were: blood pressure of 118/66 mmHg, heart rate of 85 bpm, and temperature of 38.7 °C. Physical examination revealed the point of maximum cardiac impulse in the fifth intercostal space on the right side.

An electrocardiogram showed an absence of an atypical positive P wave in leads I and aVL; instead, a negative P wave was observed. Additionally, a distinct positive R wave was present in lead aVR, and the left-sided precordial leads exhibited a prominent S wave. Conversely, the right-sided precordial leads displayed a significant R wave, suggestive of situs inversus and dextrocardia (Fig. 1A). Correction of the electrocardiogram involved reversing the left and right-hand connections, reordering chest leads (V1–V6 to V2, V1, and V3R–6R), exchanging leads II and II, swapping leads AVR and aVL, and interchanging leads V1 and V2 (Fig. 1B).Fig. 1 (A) Electrocardiogram: A negative P wave in I and aVL, a positive R wave in aVR, a prominent S wave in the left-sided precordial leads and prominent R wave in right-sided precordial leads (B) Correction of the electrocardiogram involved reversing the left and right-hand connections, reordering chest leads (V1–V6 to V2, V1, and V3R–6R), exchanging leads II and II, swapping leads AVR and aVL, and interchanging leads V1 and V2.

Fig. 1

A chest X-ray confirmed a reversed cardiac silhouette (Fig. 2). Both chest computed tomography and abdominal B-wave ultrasonography revealed abdominal visceral inversion. Echocardiography demonstrated mirror dextrocardia and mild dysmotility of the interventricular septum and posterior wall of the left ventricle, with a left ventricular ejection fraction of 40 %. His cardiac biomarker, Troponin T, was elevated at 0.254 ng/mL (reference range: 0–0.04 ng/mL).Fig. 2 A chest X-ray confirmed a reversed cardiac silhouette.

Fig. 2

Therefore, the patient was diagnosed with non-ST-segment elevation acute myocardial infarction. The NSTE-ACS risk assessment GRACE score was 127 (moderate: 109–140), and the percutaneous coronary intervention operation risk assessment (CRUSADE) score was 22 (low risk: 21–30). Given these scores, there was no indication for emergency percutaneous coronary intervention (PCI); thus, initial treatment was conservative, including dual antiplatelet drugs and statins.

The patient’s symptoms resolved, and there were no significant dynamic changes on electrocardiography. A selective coronary angiogram was performed 10 days later. The patient consented to coronary angiography (CAG), which revealed a 40 % stenosis in the coronary artery body ostium to the middle and distal segments exhibited diffuse severe stenosis, with a maximum of approximately 95 % and TIMI flow of III. The D1 ostium had a 90 % stenosis, the D2 ostium had a 50–60 % stenosis, and both with TIMI flow of III. The left circumflex artery was small (diameter less than 1.5 mm), with irregular plaques near the middle and TIMI flow of III. The right coronary artery (RCA) demonstrated 50 % stenosis in the proximal and middle segments, subtotal occlusion in the middle and distal segments, and diffuse stenosis in the distal segments. The RCA’s forward flow was TIMI grade I-II (Fig. 3).Fig. 3 Left coronary artery: (A) CRA (B) LAO 30° plus CRA 30° (C) LAO 30° plus CAU 30° (D) RAO 45° plus CAU 30°; Right coronary artery: (E) RAO 45° (F) CRA. (CRA:

Cranial; LAO: Left anterior oblique; CAU: Caudal; RAO: Right anterior oblique).

Fig. 3

Coronary artery bypass grafting (CABG) was initially recommended for the patient. However, after consulting with the cardiac surgeon, the patient’s family declined the procedure. PCI was subsequently proposed but also refused by the patient and his family. The patient was discharged from the hospital three days later on a regimen of dual antiplatelet and lipid-lowering medications. The patient was followed up twice over the subsequent two years. Aspirin, fluvastatin, and metoprolol sustained-release tablets were administered consistently, with no PCI or CABG procedures during this period.

3 Discussion

Dextrocardia can generally be divided into three types:[3] ① True right-sided heart, also known as dextrocardia, is a rare anatomical anomaly in which the heart is positioned on the right side of the chest. The positions of the atria, ventricles, and great vessels are exactly opposite to those of normal individuals, also known as the mirror-image right-sided heart. This is often accompanied by visceral transposition. ② Right-rotated heart, with the heart also located on the right side of the chest, but the relationship between the cardiac cavities is not reversed. This is caused by cardiac displacement and rotation, and is also known as a pseudo-right-sided heart. Right displacement of the heart caused by lung, pleural, or diaphragmatic diseases results in displacement of the heart to the right side of the chest. In clinical practice, a true right-sided heart (i.e. a mirror-image right-sided heart) is more common. Dextrocardia can complicate the diagnosis of myocardial infarction due to atypical presentations of symptoms. Typical symptoms of myocardial infarction, such as chest pain and discomfort, may be felt in unusual areas due to the reversed position of the heart, leading to potential misdiagnosis or delayed diagnosis. Since the patient in our case had a known history of dextrocardia, only two points need to be noted. One is the identification of dextrocardia on an electrocardiogram. In lead I, inversion of P waves and T waves, with predominantly downward QRS waves, resembling a mirror image of the usual lead I pattern; Lead II is equivalent to the usual lead III, while lead III is equivalent to the usual lead II; Lead aVR is equivalent to the usual lead aVL, while lead aVL is equivalent to the usual lead aVR. In precordial leads, V1, V2, V3, V4, V5, and V3R are respectively equivalent to the usual V2, V1, V3R, V4R, V5R, and V3 leads, while V4R and V5R are respectively equivalent to the usual V4 and V5 leads.4 Second, the right cardiac CAG precautions. No other cardiac malformations or ostial abnormalities were found in this case; therefore, the choice of guide catheter for the left radial artery approach was made. When patients with dextrocardia underwent CAG, the right side in the X-ray perspective was the descending aorta, the right side of the heart was the left coronary artery, and the left side was the RCA. It is a mirrored image of the normal left radiographic image of the heart. During left CAG, the catheter can be positioned in a posterior-anterior or right-anterior oblique 45° view and rotated counterclockwise to reach the opening of the left coronary artery. During right CAG, a right anterior oblique 45° view can be used, with the catheter similarly rotating counterclockwise to reach the opening of the RCA.

In summary, during mirror image CAG, the anterior oblique view should be changed from left to right and from right to left. However, the craniocaudal view does not require any changes. The clockwise rotation of the catheter should be changed to counterclockwise, and the counterclockwise rotation should be changed to clockwise. CAG performed in patients with right heart disease should be documented in the literature.[4,5]

Therefore, while the direct impact of anatomical abnormalities of dextrocardia on myocardial infarction remains uncertain, the distinct anatomical structure of the condition undoubtedly creates obstacles in both diagnosing and surgically treating acute myocardial infarction.

CRediT authorship contribution statement

Lin Lu: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation. Dai-Xu Li: Supervision, Resources, Methodology, Data curation.

Declaration of competing interest

We would like to state that (1): This manuscript, or part of it, neither has been published nor is currently under consideration for publication by any other journal (2); All relevant data are within the paper (3). Thanks to Li Daixu for providing us with valuable cases (4).All authors had full access to the data and agree to the manuscript as written (5); The authors have declared that no competing interests exist.

Acknowledgments

This work was supported by special fund for high-level talents in medical and health industry of Jinan City.
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