Flipping the Script: Pharmacologic Myocardial Perfusion Imaging and Percutaneous Coronary Intervention in a Patient...

Situs inversus totalis (SIT) is an extremely rare congenital abnormality in which the positions of the body's organs are mirrored. It can be accompanied by dextrocardia, where the heart is located in the right thorax with its apex pointing to the right side of the body. Its rarity poses diagnostic and therapeutic challenges, particularly in patients with coronary artery disease (CAD). We report the case of a 74-year-old woman who presented with dyspnea. Her medical history included hypertension, diabetes mellitus, hypothyroidism, and dextrocardia with SIT, incidentally diagnosed at age 45 following two cerebrovascular accidents.  She underwent pharmacologic myocardial perfusion imaging (MPI) with 99mTc-MIBI and adenosine, which revealed mild-to-moderate left ventricular dilation; a medium-sized, moderate-intensity lateral wall perfusion defect during stress; partial lateral wall redistribution at rest; and a preserved left ventricular ejection fraction of 89%. Subsequent left and right heart catheterization (LHC and RHC) and percutaneous coronary intervention (PCI) were performed via femoral access, with successful stent deployment despite the mirrored coronary anatomy. This case underscores the importance of anatomical awareness, imaging interpretation skills, and procedural adaptability when performing coronary interventions in patients with SIT and dextrocardia.