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CASE PRESENTATION A 59-year-old man with an unremarkable medical history except for tobacco abuse presented to our hospital with chest pain, dyspnea, orthopnea, and edema. His physical examination was notable for jugular venous distention, distant heart sounds, and bilateral pitting lowerextremity edema. An electrocardiogram showed negative P waves in leads I and aVL, reversed R wave progression across the anterior leads, and Q waves in leads II, III, and aVF (Figure 1). A chest radiograph demonstrated dextrocardia with a right-sided stomach bubble, indicating situs inversus (SI) totalis (Figure 2). The patient’s troponin I level was elevated to 2 ng/mL (normal value, < 0.04 ng/mL). He was started on optimized medical treatment for acute coronary syndrome, which included anticoagulation in the form of heparin and starting on aspirin and prasugrel, as well as a beta blocker. A transthoracic echocardiogram showed severely depressed left ventricular systolic function with ejection fraction of 10% to 20% and global hypokinesis. Our patient underwent left heart catheterization through the left common femoral artery approach. A Judkins JL4 catheter (Cordis Corporation, Hialeah, FL) was used to engage the right-sided anatomically located left main coronary artery. Engagement was successful with clockwise rotation of the catheter. This rotation revealed 90% stenosis in the mid left anterior descending artery (Figure 3). The right coronary artery was engaged successfully using a Judkins JR4 catheter with counterclockwise rotation. This revealed 95% stenosis in the mid vessel (Figure 4). Using an XB 3.5 catheter guide (Medtronic, Minneapolis, MN) and a balance middleweight guidewire (Abbott Industries, Abbott Park, IL), the left anterior descending lesion was crossed, and a drug-eluting stent was successfully placed. Then, a 6-French JR4 catheter guide (Abbott Industries, Abbott Park, IL) was used for right coronary artery engagement.

Image Diagnosis: Multivessel Percutaneous Coronary Intervention in Dextrocardia: Success with Usual Techniques in a Case of Mirror-Image Heart