A 69-year-old man with known situs inversus totalis and dextrocardia presented to our department due to frequent episodes of chest pain under minimal exercise (Canadian Cardiovascular Society grading of angina pectoris Class III). The patient presented with arterial hypertension, hypolipoproteinemia and nicotine abuse (45 pack years) as cardiovascular risk factors and a known history of a complex coronary three-vessel disease. About eight years ago, the patient was admitted to a hospital abroad with an acute coronary syndrome and the right coronary artery (RCA) was treated with a drug-eluting stent. Four years ago the patient had reported typical chest pain and the left main was treated with an everolimus-eluting stent as well as the proximal left anterior descending artery (LAD) and left circumflex artery (RCX) dilated in kissing balloon technique. At this previous coronary angiography, the RCA had not shown any de-novo stenosis or in-stent restenosis.
Now, the patient presented with typical chest pain and dyspnea under minimal exercise which had increased during the previous months. The patient denies palpitations or other symptoms. In the physical examination, he did not show any pathologies. The heart sounds could be auscultated on the right side of his chest without any murmurs, no peripheral edema could be seen. An ECG with the usual placement of the electrodes showed typical signs of dextrocardia: right axis deviation, positive QRS complexes (with upright P and T waves) in aVR, ‘global negativity’ (inverted P wave, negative QRS, inverted T wave) in I and absent R-wave progression in the chest leads (Fig. 1a). As recommended in the literature, an additional electrocardiogram was recorded after placing the precordial leads in a mirror-image position on the right side of the chest and reversing the left and right arm leads. As sign of the known former myocardial infarction Q-waves in II/III/aVF were present (Fig. 1b).
The laboratory findings did not show any pathologic results, especially the cardiac markers troponin and creatine kinase were normal. A transthoracic echocardiography at rest revealed a regular left ventricular function with apical hypokinesia which had already been described in the previous echocardiography. No abnormalities of the valves were seen. A stress echocardiogram by treadmill could not be performed due to severe arthralgia and significant dyspnea. Because of the typical symptoms and the complicated coronary three vessel-disease with a history of percutaneous coronary interventions and stent-implantations, the indication for a coronary angiography was given.
The vascular access was established by the right femoral artery and a 6French Terumo® sheath inserted. Due to known dextrocardia, we exceptionally preferred the femoral access over the radial access route in this specific case. The coronary angiography showed a good result after the previous left main stenting and RCX/LAD percutaneous coronary intervention (Fig. 2a). In contrast, the RCA was completely occluded in segment two right in the area of the stent that was implanted ten years before (Fig. 2b). We found collaterals from the left coronary artery system and signs of calcification (Fig. 2a), so the diagnostically criteria of a CTO were fulfilled. Collaterals were grade I – II according to Rentrop classification. The Japanese-CTO-score (J-CTO-score) [2] which describes the complexity of the lesion was 3 (due to the occlusion length of more than 20 mm, bending and the present calcification), indicating a very difficult lesion. Ventriculography showed a regular-sized left ventricle with good systolic function. Because of the present symptoms of the patient and evidence for vital myocardium by echocardiography, an ad-hoc revascularization of the CTO was attempted.
A Cordis 6F SRC® no-torque guidance catheter was used and the standard antegrade wire escalation technique attempted. A buddy-wire (Abbott® BMW-CW) was inserted in a right-ventricular branch of the RCA. A Terumo Finecross® microcatheter was inserted with the help of a BMW-wire which was exchanged to an Abbott Hi-Torque Progress 200 T® which allowed the successful recanalization (Fig. 3a/b). Due to rapid guidewire success and clear demarcation of the CTO segment, we refrained form using a second arterial access to visualize collaterals. Balloon angioplasty was performed with Terumo Tazuna® 1.25/10 mm, Boston Scientific Maverick® 1.5/20 mm and Abbott NC Trek® 2.5/20 mm (eight insufflations with 16 bar maximum, Fig. 3c). Two everolimus eluting stents (Abbott Xience Pro® 2.5/23 mm with 18.0 bar and Xience Pro 2.75/23 mm with 14 bar) were successfully implanted with very good angiographic result (Fig. 3d).
The patient was loaded with clopidogrel for dual platelet aggregation inhibition in addition to his premedication with aspirin. Overall, 254 ml of contrast agent were used during this procedure. Even though the J-CTO-score (indicating the complexity of the lesion) was 3 and thus higher than the average at our department (which is 2,46), the lesion could be treated faster (116 min vs 126 min) and with lower fluoroscopy time (23 min vs 28,3 min) than the average at our department.
After the procedure, there was no clinical sign for pericardial effusion and no significant elevation of cardiac markers. The patient reported no symptoms and was discharged the next day after the procedure.
