Is urinary catheterization more challenging in patients with dextrocardia (a congenital heart condition where the heart is on the right side of the chest)?

Cardiac Catheterization in Dextrocardia

Cardiac catheterization in patients with dextrocardia is technically more challenging than in patients with normal cardiac anatomy, but it is safe and feasible when performed at specialized centers with expertise in congenital heart disease. 1

Technical Challenges During Catheterization

The primary difficulties stem from the altered cardiac position and vascular anatomy:

• Mirror-image anatomy requires operators to mentally reverse their usual spatial orientation, affecting catheter manipulation and fluoroscopic image interpretation 2
• Variable coronary artery anatomy impacts catheter selection, with multipurpose catheters often being the most versatile choice for engaging coronary ostia 2
• Standard catheter shapes designed for normal anatomy may not engage vessels appropriately, requiring alternative catheter selections 2, 3
• Fluoroscopic imaging must be adjusted using mirror-image settings to maintain proper orientation during the procedure 2

Guideline-Based Recommendations

The ACC/AHA guidelines explicitly state that adults with complex congenital heart disease, including dextrocardia, should have catheterization performed at centers with expertise in catheterization and management of such patients. 1 This recommendation carries a Class I indication, reflecting the highest level of consensus that specialized expertise is essential. 1

The rationale is straightforward: dextrocardia frequently occurs with additional complex cardiac malformations (present in all patients in one large series), and these anatomic variants require experienced operators who understand the altered spatial relationships. 4, 5

Specific Anatomic Considerations

Dextrocardia presents in different forms, each with distinct implications:

• Situs inversus with dextrocardia (most common at 39.2%) typically has more predictable mirror-image anatomy, though 73.4% still have concordant atrioventricular connections with various conotruncal anomalies 4
• Situs solitus with dextrocardia (34.4%) has higher rates of discordant connections (41.9%) and only 7% have normal intracardiac anatomy 4
• Situs ambiguous (26.4%) carries the highest complexity, with right isomerism showing 86.9% cyanosis and 39.1% univentricular connections 4

Practical Approach to Catheterization

When performing catheterization in dextrocardia patients:

• Arterial access via radial approach is safe and effective, and should be used without hesitation 2
• Multipurpose catheters should be readily available as they provide the most versatility for engaging vessels in altered anatomy 2
• Pre-procedure imaging with echocardiography, CT, or MRI is essential to define the specific anatomic variant and plan catheter strategy 1, 3
• Coronary angiography requires particular attention to catheter selection, as standard Judkins catheters designed for left-sided aortas may not engage coronary ostia appropriately 3

Success Rates and Outcomes

Despite the technical challenges, outcomes are comparable to standard catheterization when performed by experienced operators:

• Diagnostic and therapeutic interventions including primary angioplasty and multivessel stenting have been successfully performed 6
• Coronary revascularization shows morbidity rates comparable to patients with normal anatomy when careful preoperative imaging and appropriate surgical techniques are employed 3
• Medium-term survival in adults with dextrocardia managed at specialized ACHD centers is good, even in those with complex associated lesions requiring multiple interventions 5

Critical Pitfalls to Avoid

The most important consideration is not attempting complex catheterization in dextrocardia patients at centers without congenital heart disease expertise. 1 The altered anatomy, frequent associated malformations (100% in one series), and need for specialized catheter techniques make this a procedure that should be referred to regional centers. 1, 4

Additionally, operators must recognize that obtaining diagnostic images may be difficult or even impossible in some cases of dextrocardia, particularly with mesocardia or complete dextrocardia, requiring non-standard imaging planes adjusted to each patient. 1