IJCS | Volume 33, Nº2, March / April 2020

193 Cunha et al. Situs inversus in man submitted to angioplasty Int J Cardiovasc Sci. 2020; 33(2):192-196 Case Report segment of the right coronary artery and also revealed the anomalous origin of the right coronary artery from the left sinus. On the following day, the patient underwent successful angioplasty with stent implantation. He evolved with clinical improvement and was discharged with a prescription for the following medications: ASA, atenolol, enalapril and simvastatin.Twoweeks after this procedure, the patient was in good general condition and asymptomatic. To the physical examination, he presentedwith a heart rate of 53 bpm, a respiratory rate of 18 breaths/min and blood pressure of 135/90 mmHg. The heartbeat was regular with two clicks and normal sound without murmurs. The conventional electrocardiogram (ECG) performed after the angioplasty showed typical dextrocardia pattern and electrocardiographic changes characteristic of inferior wall infarction. A nuclear magnetic resonance (NMR) imaging of the abdomen confirmed situs inversus totalis, with the liver on the left side and the spleen on the right side. An important aspect to point out is the patient’s lack of risk factors for coronary events. Discussion The importance of the electrocardiographic diagnosis of dextrocardia is essential in the acute phase of coronary heart disease, especially in cases of clinical emergency, in which there is a need for immediate treatment with direct prognostic implications. Other aspects of importance are clinical reasoning and semiologic diagnosis, essentially by physical examination, in pathologies that involve dextrocardia and/or situs inversus totalis. In these specific cases, we highlight the relevance of the epidemiology, clinical features, hemodynamics and anatomic abnormalities, through which we verify: frequency and disease-association in the population in general; the presence of coronary artery disease; acute coronary events and primary percutaneous intervention and, finally, right coronary artery originating from left coronary sinus and anomalous pathway. In other words, the association of benign andmalignant anomalies in the same patient. Hence the need for early identification and the importance of clinical reasoning. Coronary angiography and percutaneous coronary intervention (PCI) in these patients are technically difficult and require certain modifications, such as mirror image angiographic angulation, proper catheter selection and catheter manipulation for selective cannulation of coronary arteries. 8 Regardless of the unusual anatomy, percutaneous coronary intervention in patients with coronary artery disease and dextrocardia is normally successful. 9 PCI can be safely performed using femoral or radial approaches, although as shown by previous case reports of PCI for AMI in patients with the mirror-image dextrocardia, it is conventionally performedwith femoral arterial access. 10 In this case, the coronary angiography was performed via the right radial artery. Contrast injection into the aorta revealed dextrocardia and anomalous origin of right coronary artery from left coronary sinus. Catheterization of left coronary arterywas performed using a JL4 catheter and showed absence of severe obstructive atherosclerotic lesions. Due to the anomalous origin of the right coronary artery, an AL2 catheter was used for characterization, which showed a 90% lesion in the proximal segment of the right coronary artery. We decided to perform a coronary angioplasty and to implant a conventional stent, 3.5/14 mmwith a pressure of 14 atm, followed by dilating force at the target lesion with a 4.0/10 mm balloon, inflated to a pressure of 12 atm. Control angiography shows a good final angiographic result. Dextrocardia accompanied by atherosclerotic coronary disease has been poorly described in the literature, but it can be treated with percutaneous coronary intervention. The procedure was performedwithmovements contrary to the usual, showing that coronary angioplasty can be used to treat these patients. Author contributions Conception and design of the research: Fuchs A. Acquisition of data: Cunha IAT, Mour o JRC, Lora LB, Duarte FCC. Analysis and interpretation of the data: Cunha IAT, Mour o JRC, Lora LB, Duarte FCC. Statistical analysis: Catanheda CRO. Writing of the manuscript: Cunha IAT, Mour o JRC, Lora LB, Duarte FCC. Critical revision of the manuscript for intellectual content: Fuchs A, Catanheda CRO. Supervision / as the major investigador: Catanheda CRO. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported.