Key result
Intracoronary isosorbide dinitrate completely resolves severe left main spasm in situs inversus totalis.
Why the study?
The association between situs inversus totalis, a rare congenital mirror-image visceral arrangement, and coronary artery spasm causing ACS is exceptional.
Case Report (n=1)
No
This case highlights the necessity of adapting ECG and angiographic techniques to mirror-image anatomy in situs inversus totalis and performing intracoronary nitrate testing to exclude coronary spasm before revascularizing left main stenoses.
Requires adapted ECG and angiographic techniques in situs inversus totalis; leaves open nitrate testing before left main revascularization.
Introduction and importance: Situs inversus totalis (SIT) is a rare congenital mirror-image arrangement of the viscera. Coronary artery spasm (CAS) is a transient, intense vasoconstriction of an epicardial coronary artery that can cause acute coronary syndrome (ACS). Their association is exceptional. Case presentation: A 51-year-old hypertensive woman presented with prolonged right-sided chest pain. Examination, electrocardiography (ECG), chest radiography and computed tomography revealed previously unknown SIT. The ECG recorded with mirror-image electrode placement showed diffuse ST-segment depression with ST elevation in aVR, and troponin was rising (NSTE-ACS). Coronary angiography, performed with mirror-image catheter manipulation, showed a 70–80% left main narrowing reproducing the chest pain, which resolved completely after intracoronary isosorbide dinitrate. Medical treatment led to a favourable outcome. Clinical discussion: In SIT, ECG recording and coronary angiography must be adapted to the mirror-image anatomy. Left main spasm must be distinguished from fixed atherosclerotic disease and catheter-induced spasm before any revascularization. Conclusion: Intracoronary nitrate testing is mandatory before treating any left main narrowing, particularly in unusual anatomy.
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Fihri et al. (2026) conducted a case report in Left main coronary artery spasm presenting as non-ST-elevation acute coronary syndrome in situs inversus totalis (n=1). Intracoronary isosorbide dinitrate followed by non-dihydropyridine calcium channel blocker and long-acting nitrates was evaluated on Resolution of left main coronary artery spasm and recurrent angina. Intracoronary isosorbide dinitrate completely resolved a 70-80% left main coronary artery spasm in a 51-year-old woman with situs inversus totalis, with no angina recurrence over 5 months.
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