PCI of Calcified LAD/D1 Bifurcation Lesion in Patient with Dextrocardia – Dec 2012

Case: 78-year-old female with NIDDM, dextrocardia & situs inversus presented on 9/7/12 with NSTEMI; and cath revealed 2V CAD and normal LV function (SYNTAX score 17). Patient underwent PCI using rotational atherectomy and two Eeverolimus-eluting stents of culprit RCA. Patient continues to do well except for CCS Class II angina. Now scheduled for PCI of calcified LAD/D1 bifurcation lesion in this anatomically challenging patient with dextrocardia.

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Q&A

Q What lead to the diagnosis of dextrocardia for your patient?
A. Patient had long standing diagnosis of Dextrocardia and Situs Inversus since childhood. The EKG was also classic with QS in Lead I and qR in lead aVR (looks as arm lead reversal but is classical for dextrocardia).
Q Were there non-invasive investigations?
A. Yes this patient had echo stating that heart is not in its correct position. No MPI study done.
Q Should one always recommend such incidental patients to an expert dealing with Congenital diseases of the adult?
A. I do not think so unless pt has complex valvular or extensive coronary artery disease.
Q We did not review the EKG on this patient - was it classical for dextrocardia?
A. Yes; S wave in lead I and R wave in aVR along with poor ‘R’ wave progression in regular left sided precordial leads.
Q What is the preferred approach for such patients - trans femoral always?
A. Yes Transfemoral as Transradial may be tricky unless you are an expert in TRI procedures
Q Should mirror image angiographic views suffice? Or should one obtain special views?
A. As we showed, all angiographic views are mirror image and simple to pan and follow keeping the dextrocardia in mind.
Q What is the correct way and the best view to engage the RCA in dextrocardia?
A. RAO view and counterclockwise movement of the JR catheter.
Q Any other special technical features to handle PCI in dextrocardia patients?
A. Just roadmap the coronary view to avoid foreshortening.
Q Besides gut instincts, what criteria do you use to down size a burr size for rotablation?
A. Ablation time of more than 200 seconds; means 7-8 attempts of 20sec runs. In that scenario, I will recommend downsizing the burr.
Q Do you always first attempt a rota wire or in some cases, proceed to exchange over an OTW balloon or exchange catheter?
A. In approximately 70% of cases we use OTW device (usually Finecross Catheter) with our workhorse wire (Runthrough NS or Fielder) and then exchange with the Rotafloppy wire. Only in 1/3 cases (like 70-90% lesion in non-tortuous prox LAD/RCA), I advise to go with the Rotawire directly.

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