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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 18  |  Issue : 3  |  Page : 100-103  

Off-pump coronary artery bypass surgery in a patient with dextrocardia and situs inversus: Anesthetic, surgical consideration and role of transesophageal echocardiography


Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Date of Web Publication8-Nov-2017

Correspondence Address:
S Subash
Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagara 9th Block, Bengaluru - 560 069, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_5_17

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   Abstract 

Coronary artery bypass surgery (CABG) in dextrocardia with situs inversus patients is reported less in literature. Due to abnormal looping and associated other congenital anomalies, anesthetic implications and surgical difficulties become challenging in these patients. Transesophageal echocardiography examination (TEE) needs multiplane angle adjustments compared to normal heart to obtain the images. Here, we describe a 53-year-old female patient having dextrocardia with situs inversus who underwent CABG and discuss the perioperative management and multiplane adjustments during TEE examination.

Keywords: Coronary artery bypass surgery, dextrocardia, situs inversus, transesophageal echocardiography


How to cite this article:
Subash S, Simha PP, Manjunatha N. Off-pump coronary artery bypass surgery in a patient with dextrocardia and situs inversus: Anesthetic, surgical consideration and role of transesophageal echocardiography. Heart Views 2017;18:100-3

How to cite this URL:
Subash S, Simha PP, Manjunatha N. Off-pump coronary artery bypass surgery in a patient with dextrocardia and situs inversus: Anesthetic, surgical consideration and role of transesophageal echocardiography. Heart Views [serial online] 2017 [cited 2019 Jul 18];18:100-3. Available from: http://www.heartviews.org/text.asp?2017/18/3/100/217853


   Introduction Top


Dextrocardia with situs inversus is a rare congenital abnormality with an incidence of 1:10,000.[1] It involves a left-handed malrotation of the visceral organs. The incidence of coronary artery disease in these patients is similar to that of the general population.[2]

Coronary artery bypass surgery (CABG) operations in dextrocardia patients are a challenging task to the operating surgeon due to the position of the heart. Here, we discuss the anesthetic management, surgical difficulties, and various multiplane angle adjustments required during transesophageal echocardiography (TEE) examination.


   Case Presentation Top


A 53-year-old obese female patient presented with the right-sided chest pain and dyspnea on exertion for 2 years. Her vital signs on admission were HR: 88/min, BP: 130/90 mmHg, RR: 14/min and Spo2 100%. She was a known case of diabetes mellitus, hypertension, hypothyroidisim, and bronchial asthma on regular treatment.

Seven years back, she had undergone stenting to left anterior descending (LAD) coronary artery.

Electrocardiogram (ECG) showed invertedP wave along with negative QRS complex in lead I, positive QRS deflection in lead aVR, and poor progression of R wave in chest leads. Chest X-ray showed dextrocardia and abdominal ultrasound examination confirmed the presence of situs inversus. Coronary angiogram showed ostial morphologic LAD occlusion (in-stent restenosis) and 90% discrete lesion in morphologic left circumflex with right dominance. Transthoracic echocardiography showed dextrocardia with ejection fraction of 45%, with regional wall motion abnormalities in LAD territory. Her biochemical and hematological investigations were with normal limits. She was referred for coronary artery bypass grafting surgery.

Induction was done as per the standard protocol for CABG patients, 7.5F central line was introduced in the left internal jugular vein and ECG leads were placed in the right side in view of dextrocardia. TEE probe was introduced without any difficulty. Intraoperative TEE images were recorded.

In contrary to the TEE images in situ s, in midesophageal (ME) four chamber view, the right atrium and right ventricle (RV) were seen in the left side of the image sector at 0° [Figure 1] and [Video 1]. In ME two chamber view, the structures were similar to the normal heart [Figure 2] and [Video 2]. ME long-axis view (LAX) was obtained at an angle of 40°, in contrary to an angle of 120° in normal heart [Figure 3] and [Video 3]. ME modified bicaval view was obtained at an angle of 60°, in contrary to an angle of 110°–120° in normal heart [Figure 4] and [Video 4]. ME aortic valve short-axis view (SAX) was obtained at angle of 120° in contrary to an angle of 30° in normal heart [Figure 5] and [Video 5]. Coronary sinus was seen after slight retroflexion of the probe from ME four chamber view, in the left side of the image sector at 0° in contrary to the right side of the image sector in normal heart [Figure 6] and [Video 6]. ME ascending aorta SAX was obtained at 0° with pulmonary artery on the left of the image sector and superior vena cava on the right side [Figure 7] and [Video 7]. ME ascending aorta LAX view was similar to normal heart at 90° [Figure 8] and [Video 8]. In transgastric (TG) basal and mid-papillary SAX view, left ventricle was seen on the right side of the image sector [Figure 9] and [Video 9]. TG two chamber view was similar to normal heart [Figure 10] and [Video 10]. TG right ventricular inflow-outflow view was obtained at 55° in contrary to 110°–120° in normal heart [Figure 11] and [Video 11]. ME descending thoracic aorta view was similar to normal heart [Figure 12] and [Video 12].
Figure 1: Midesophageal four chamber view

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Figure 2: Midesophageal two chamber view

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Figure 3: Midesophageal left ventricle long-axis view

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Figure 4: Midesophageal modified bicaval view

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Figure 5: Midesophageal aortic valve short-axis view

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Figure 6: Midesophageal coronary sinus view

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Figure 7: Midesophageal ascending aorta short-axis view

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Figure 8: Esophageal ascending aorta long-axis view

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Figure 9: Transgastric mid short-axis view

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Figure 10: Transgastric two chamber view

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Figure 11: Transgastric right ventricle inflow-outflow view

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Figure 12: Midesophageal descending thoracic aorta short-axis view

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After median sternotomy, right internal mammary artery (RIMA) was harvested. RIMA was anastomosed to morphological LAD and saphenous venous graft was anastomosed to the marginal branch. The operating surgeon was on the left side of the patient while operating. After surgery, the patient was shifted to postoperative intensive care unit, extubated after 4 h of mechanical ventilation, and discharged without any complication.


   Discussion Top


Dextrocardia is a rare cardiac anomaly in which the heart is located in the right hemithorax and its base to apex axis is directed toward the right side. In situ s inversus, the chest and abdominal organs are arranged in mirror image reversal of the normal position.

The anatomist surgeon, Hieronymus Fabricius, first described dextrocardia in 1606.[3] Marco Aurelio Severinus first described dextrocardia with situs inversus in 1643.[4] The first CABG was done in a patient with dextrocardia in 1980.[5]

Embryologically, dextrocardia with situs inversus is due to 270° clockwise rotation of the developing thoracoabdominal organs instead of the normal 270° counterclockwise rotation.[6] Dextrocardia can be associated with other cardiac anomalies with isolated dextrocardia but rare in situ s inversus totalis with dextrocardia.

Anesthetic consideration in dextrocardia includes proper preoperative evaluation, placement of ECG electrodes in the opposite side, introduction of central venous catheter in the left side internal jugular vein because of its straight course to the anatomical left atrium.

In dextrocardia, the presence of RV on the left side and anterior to the left ventricle also coursing of LAD on the right side of the heart makes revascularization of LAD with left internal mammary artery (LIMA) difficult because of the short course of LIMA. Usually, RIMA is anastomosed to LAD, considering its proximity to rightward LAD.[7]

Most surgeons prefer to stand on the left side of the patient while anastomosing in dextrocardia patients due to the position of the heart. However, there are reports showing surgeons operating in the conventional position as well.[8] In case of on-pump CABG, location of aortic arch should be considered before aortic cannulation as in dextrocardia, aortic arch may be right sided.[9] The presence of bilateral superior vena cava has to be checked before venous cannulation.[10]

TEE examination in dextrocardia patients needs probe and multiplane plane angle manipulations due to abnormal looping. TEE views such as ME four chamber view, ME aortic SAX axis view, and TG basal/mid SAX view appear as mirror image of the normal heart. TEE images obtained at 120° in ME aortic LAX view are obtained at 30°–40° in dextrocardia patients. However, TEE views obtained at an angle of 90° in dextrocardia patients are similar to normal heart.


   Conclusion Top


CABG in dextrocardia patients is challenging and can be performed successfully. Careful perioperative evaluation, intraoperative positioning of heart, selection of conduits and graft configuration, multiplane angle and probe adjustments in TEE are needed due to abnormal looping of heart in dextrocardia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Rosenberg HN, Rosenberg IN. Simultaneous association of situs inversus, coronary heart disease and hiatus hernia; report of a case and review of literature. Ann Intern Med 1949;30:851-9.  Back to cited text no. 1
[PUBMED]    
2.
Hynes KM, Gau GT, Titus JL. Coronary heart disease in situ s inversus totalis. Am J Cardiol 1973;31:666-9.  Back to cited text no. 2
[PUBMED]    
3.
Cleveland M. Situs inversus viscerum: Anatomic study. Arch Surg 1926;13:343.  Back to cited text no. 3
    
4.
Brown JW. Congenital Heart Disease. London: Staples Press Ltd.; 1950.  Back to cited text no. 4
    
5.
Irvin RG, Ballenger JF. Coronary artery bypass surgery in a patient with situs inversus. Chest 1982;81:380-1.  Back to cited text no. 5
[PUBMED]    
6.
Song JY, Rana N, Rotman CA. Laparoscopic appendectomy in a female patient with situs inversus: Case report and literature review. JSLS 2004;8:175-7.  Back to cited text no. 6
[PUBMED]    
7.
Chui WH, Sarkar P. Coronary artery bypass grafting in dextrocardia with situs inversus totalis. J Cardiovasc Surg (Torino) 2003;44:617-9.  Back to cited text no. 7
    
8.
Saad RA, Badr A, Goodwin AT, Dunning J. Should you stand on the left or the right of a patient with dextrocardia who needs coronary surgery? Interact Cardiovasc Thorac Surg 2009;9:698-702.  Back to cited text no. 8
    
9.
Arcilla RA, Gasul BM. Congenital dextrocardia. Clinical, angiocardiographic, and autopsy studies on 50 patients. J Pediatr 1961;58:251-62.  Back to cited text no. 9
    
10.
Murtuza B, Gupta P, Goli G, Lall KS. Coronary revascularization in adults with dextrocardia: Surgical implications of the anatomic variants. Tex Heart Inst J 2010;37:633-40.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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