Non–ST-Elevation Myocardial Infarction in Dextrocardia : Challenges in Coronary Angiography and Percutaneous Coronary Intervention

Abstract

Background: Dextrocardia is a rare congenital condition characterized by right-sided cardiac positioning, which may complicate electrocardiographic interpretation and coronary angiography. In patients presenting with non–ST-elevation myocardial infarction, subtle or absent ST-segment changes may increase diagnostic uncertainty when clinical suspicion is not maintained. Case Summary: A male patient with type 2 diabetes mellitus and chronic tobacco use presented with typical retrosternal chest pain radiating to the back. Troponin I was markedly elevated, while the initial ECG showed no significant ST-segment elevation or depression. Transthoracic echocardiography demonstrated moderately reduced left ventricular ejection fraction with apical hypokinesia. The patient was transferred for urgent coronary angiography via right radial access. Angiography demonstrated dextrocardia-associated anatomical inversion, requiring adapted catheter manipulation and reversed angiographic projections. The left coronary system was engaged using a Judkins Right catheter, and an inverted “spider” projection was used to visualize the left main and circumflex arteries, which were free of significant disease. A subocclusive proximal left anterior descending artery lesion was identified and treated by percutaneous coronary intervention using guidewire crossing, balloon predilation, and drug-eluting stent implantation, resulting in satisfactory angiographic outcome and TIMI III flow. Right coronary artery cannulation was challenging and ultimately achieved with a multipurpose catheter; a 70% lesion was planned for staged treatment. Conclusion: This case highlights the diagnostic and procedural challenges of NSTEMI in dextrocardia and emphasizes the importance of recognizing mirror-image anatomy, adapting projections, and maintaining flexibility in catheter selection during coronary intervention.