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Paper text:
mirror image dextrocardia was first noted in the 1920s and it may be present in about one in 130,000 people . although dextrocardia occurs rarely , the incidence of coronary artery disease is similar to the general population.1)2 ) successful coronary angiography and angioplasty via the femoral artery have previously been performed in patients with dextrocardia.3)4 ) but , there has been no report on transradial coronary angiography in a patient with dextrocardia in korea .
we report a case of successful transradial coronary angiography in a patient with right sided heart .
exercise testing using the bruce protocol reproduced his symptoms within the second stage of the test . because of his right handedness
selective coronary angiograms were obtained using counter - directional torquing of judkins left-4 and amplatz left-2 catheters and mirror - image angiographic angles .
the left main coronary artery was 60% stenosed in the distal bifurcation , with significant narrowing of both proximal left anterior descending and left circumflex arteries ( fig .
the non - dominant right coronary artery was diffusely occluded at its mid segment ( fig .
2 ) . he received bypass surgery due to multivessel disease with left main stem involvement . instead of the left internal mammary artery ,
dextrocardia is a rare cardiac condition in which the incidence of coronary artery disease is presumably similar to the general population.1)2 ) since the first diagnostic cardiac catheterization in a patient with dextrocardia in 1973,2 ) few have reported transfemoral catheterization procedures.3)4 ) the most important modifications in performing coronary angiogram in patients with dextrocardia are opposite - direction catheter rotations and mirror - image angiographic angles , i.e. , anticlockwise rotation in the ascending aorta for the right coronary artery and reversing the required right anterior oblique / left anterior oblique angles but keeping the cranial / caudal tilts the same.3)4 ) other angiographers used a double - inversion technique , which normalizes all angiographic pictures to the standard conventional pictures as seen in a normally located heart.5 ) in our case , we performed coronary angiography with a novel transfemoral approach , the counter - directional torquing of the catheter , as well as right - left mirror - image inversion angiographic views.3)4 ) we did not do further image reversal to employ traditional views .
nowadays , transradial coronary angiography is gaining popularity because it can make patients comfortable , reduce vascular complications , and allows earlier ambulation than the transfemoral technique.6 ) however , there has been no report on transradial coronary angiography in these patients in korea .
although transradial angiography is probably more difficult than transfemoral angiography due to potential subclavian or innominate arterial tortuosity and/or angulation , we selected transradial coronary angiography . moreover , we chose a left approach because of his right handedness .
we assumed that the left transradial approach might be similar to right transradial angiography in patients with normal heart position , except for the unfamiliarity for angiographer .
moreyra et al.3 ) reported that regular coronary catheters ( judkins ) are difficult to use because of the reversed position of the coronary ostia , and recommended nontraditional catheters with wider curves and longer tips .
otherwise , both the left and right coronaries were successfully cannulated with judkins catheters in other reports.4 ) in our case , left coronaries were easily engaged with a judkins left-4 catheter , but we used an amplatz left-2 catheter for the right coronary artery because of its tortuosity and leftwardly displaced origin .
the use of opposite - directional torquing of these catheters in mirror - image angiographic angles allowed uncomplicated left transradial angiography in a patient with right sided heart , dextrocardia . in summary ,
our report demonstrates the feasibility of left transradial angiography in the rare patient with dextrocardia , suggesting its potential as a simple approach to the right sided heart .
although dextrocardia occurs rarely , the incidence of coronary artery disease is similar to the general population . because of unfamiliarity with performing catheterization 
 , transradial coronary angiography has seldom been performed in a patient with dextrocardia . 
 we successfully performed left transradial coronary angiography in a patient with a right side heart using counter - directional torquing of the catheters and mirror - image angiographic angles .