Coronary Artery Bypass Grafting in a Patient With Multivessel Disease and Dextrocardia With Situs Inversus Totalis

Dextrocardia with situs inversus totalis is a rare hereditary condition characterized by reversed orientation of the major thoracic and abdominal organs. Though dextrocardia itself is not believed to increase the risk of coronary artery disease, the workup and surgical management of patients with this condition may be technically challenging to heart team clinicians. This report describes the case management of a high-risk 56-year-old man with dextrocardia who presented with multivessel coronary artery disease.

Congenital hemivertebrae combined with situs inversus totalis: A rare case report

RATIONALE

Situs inversus totalis is a rare malposition of organs that typically involves lesions in the respiratory, circulatory, or urinary systems. Cases of congenital hemivertebrae combined with situs inversus totalis are extremely rare and have limited reports.

PATIENT CONCERNS

We report a 2.5 years old girl with 2 congenital hemipyramids and complete visceral inversion who ultimately underwent hemilaminectomy.

DIAGNOSIS

Congenital hemivertebrae combined with situs inversus totalis.

INTERVENTION

The patient underwent hemilaminectomy.

OUTCOMES

The spinal deformity was corrected.

LESSONS

For patient with spinal deformities combined with situs inversus totalis, surgery can be an effective treatment method. But we also need to be vigilant about the dysfunction of various systems.

Percutaneous coronary intervention for chronic total occlusion of the left circumflex branch in mirror dextrocardia: a case report

BACKGROUND

Mirror dextrocardia (MDC) is a condition in which the heart is located in a mirror-image position on the right side of the chest compared to the normal position in individuals with physiological variations. Patients with MDC and chronic total occlusion (CTO) of the left circumflex branch (LCX) are extremely rare in clinical practice. The treatment of MDC-CTO-LCX differs significantly from patients without mirror dextrocardia and the same condition in terms of instrument selection and procedural techniques. In this article, we report a successful case of interventional treatment in a patient with MDC-CTO-LCX. We summarize the anatomical and electrocardiographic variations in patients with MDC-CTO-LCX, and discuss the selection of interventional instruments and techniques that can be useful for interventionists as well as the diagnostic and therapeutic considerations that can be helpful for clinical physicians.

CASE PRESENTATION

A male Han Chinese patient, 51, was admitted, presenting recurrent chest pain for a year and recent onset of exertional fatigue over the past week.He reported episodes of chest pain following physical activities over the past year, lasting between 5 and 20 min.Despite these symptoms, the patient did not seek immediate medical attention, and the occurrence of his chest pain has progressively lessened within the year.A week prior, the patient developed exertional dyspnea after brief walks, though without any episodes of nocturnal paroxysmal dyspnea.Upon arrival at our hospital for evaluation, he was initially diagnosed with chronic coronary syndrome, previous inferior myocardial infarction, atrial arrhythmia, and classified under the New York Heart Association functional class III.Following his admission, a chest X-ray and coronary angiography were conducted.The results indicated mirror dextrocardia and total occlusion of the left circumflex branch. Percutaneous coronary intervention (PCI) was performed on the left circumflex branch. Subsequent angiography demonstrated optimal stent positioning without evidence of hematoma or dissection.Following the procedure, the patient's symptoms of chest pain and exertional dyspnea were resolved, which led to his subsequent discharge.A follow-up electrocardiogram, 10 months post-procedure, displayed a slow and regular atrial rhythm.

CONCLUSIONS

The incidence of dextrocardia is very low, and it may appear normal on an electrocardiogram; however, careful diagnosis is required when there is an abnormal direction of the P wave in limb leads. During the operation for chronic occlusive lesions of the right-sided coronary artery, the anomalous anatomical structure necessitates specific requirements for instrument selection and operative techniques. After revascularization of chronic occlusive vessels in dextrocardia, routine electrocardiographic examination may show false normalization, requiring caution in interpretation.

Outcomes of the Arterial Switch Operation in Patients With Dextrocardia

BACKGROUND

Patients with dextrocardia and d-transposition of the great arteries (d-TGA) present a technical challenge when performing the arterial switch operation (ASO). We sought to determine the long-term outcomes of this rare presentation.

METHODS

All patients who underwent the ASO with d-TGA and dextrocardia were identified from the hospital database.

RESULTS

There were four patients with dextrocardia (4 of 844, 0.5%) patients; two patients had situs solitus and two patients had situs inversus. Three patients had a ventricular septal defect. Left ventricular outflow tract obstruction was present in one patient and one patient had a hypoplastic arch with severe coarctation of aorta. Anomalous coronary anatomy occurred in two patients. There was one early mortality and the cause of death was sepsis. One patient required late reoperation for severe neo-pulmonary valve regurgitation at 23 years after the ASO. At last follow-up, all three surviving patients were in New York Heart Association Class I.

CONCLUSIONS

Patients with d-TGA and dextrocardia who undergo the ASO are extremely rare and require challenging operative management.

Mitral valve repair in patients with mirror-image dextrocardia and situs inversus: two cases and a review of the literature

Dextrocardia is a rare cardiac malposition that was first described in 1606. Mirror-image dextrocardia is characterized by a mirror-image change of the normal position of the heart. Most cases are accompanied by situs inversus viscerum, whereas only 3% to 10% of cases are associated with intracardiac anomalies. Valve surgery for acquired valvular lesions in patients with mirror-image dextrocardia with situs inversus is rare. Diagnosing situs anomalies in adults is important to prevent errors during surgical operations, emergency procedures, or interventional operations. In this report, we present two cases of mitral regurgitation in patients with mirror-image dextrocardia. One patient had mirror-image dextrocardia with subacute infective endocarditis and mitral regurgitation, and the other patient had mirror-image dextrocardia with mitral Carpentier type I regurgitation. In both patients, mitral valve repair was successfully performed using a transseptal approach.

[Stanford Type A Aortic Dissection with Tricuspid Regurgitation in a Patient with Situs Inversus Totalis]

Situs inversus totalis is a congenital anomaly characterized by a mirror image transposition of the normal visceral organs, which makes it difficult to perform aortic surgery accurately. Stanford type A aortic dissection in patients with this condition is very rare and difficult to assess and manage. We report a case of Stanford type A aortic dissection with situs inversus totalis. The patient presented with severe tricuspid regurgitation with annulus enlargement due to chronic atrial fibrillation, requiring ascending aortic replacement and tricuspid annuloplasty. These procedures were performed after the operator swapped the left and right positions during the operation. Postoperative course was uneventful. By carefully checking the preoperative computed tomography images and changing the operator's position during the operation, it is possible to safely perform Stanford type A aortic dissection surgery in patients with situs inversus totalis.

Emergency thrombectomy for cerebrovascular occlusion in a patient with mirror-image dextrocardia: a case report

Cases of patients complicated with dextrocardia who suffer from acute cerebral infarction with large vessel occlusion and receive emergency thrombectomy are particularly rare and have not been widely reported. This article aimed to increase the awareness and knowledge of these cases. We report the case of a patient with mirror-image dextrocardia who suffered from cerebral infarction with large vessel occlusion and received emergency thrombectomy. A male patient in his early 60s with dextrocardia had acute cerebral infarction with posterior circulation large vessel occlusion and underwent emergency thrombectomy. During the operation, the rapid confirmation of dextrocardia and use of flexible interventional instruments helped establish a pathway for blood flow. We used an intracranial thrombectomy stent and intracranial balloon dilation catheter to restore the cerebral blood supply. The Modified Rankin Scale score was 0 at 3 months after thrombectomy, indicating a good prognosis of the patient. Acute cerebral infarction with large vessel occlusion in patients with dextrocardia is extremely rare. Emergency thrombectomy is feasible to recanalize cerebral blood flow and give patients a chance to recover.

Human Laterality Disorders: Pathogenesis, Clinical Manifestations, Diagnosis, and Management

Human laterality disorders comprise a group of diseases characterized by abnormal location (situs) and orientation of thoraco-abdominal organs and vessels across the left-right axis. Situs inversus totalis is mirror image reversal of thoraco-abdominal organs/great vessels. Situs ambiguus, better known as heterotaxy, is abnormal arrangement of thoraco-abdominal organs across the left-right axis excluding situs inversus totalis. Heterotaxy, also referred to as atrial or atrial appendage isomerism, is characterized by abnormal location of left-sided or right-sided organs with loss of asymmetry of normally paired asymmetric organs. It is associated with a variety of anomalies involving the heart, great vessels, lungs and intra-abdominal organs. Right and left atrial isomerism are associated with multiple complex congenital cardiac and vascular anomalies, many of which are lethal when untreated. Isomerism may also affect the lungs, spleen, liver, gall bladder, and intestines. Innovative surgical therapy of heterotaxy/isomerism has reduced early mortality and markedly improved long-term prognosis.

[Double Valve Replacement and Tricuspid Annuloplasty in a Patient with Situs Inversus Totalis and Mirror-image Dextrocardia;Report of a Case]

Situs inversus totalis and mirror-image dextrocardia is a rare congenital anomaly. A 79-year-old man with a history of atrial fibrillation presented to our hospital with chest oppression. Chest X-ray and computed tomography showed mirror-image dextrocardia and situs inversus totalis. Echocardiography revealed severe mitral and aortic regurgitation and mild tricuspid regurgitation. Mitral and aortic valve replacement using bioprosthesises, tricuspid annuloplasty and closure of the left atrial appendage were successfully performed. Surgical procedures were mainly performed by the surgeon standing on the left side of the patient, and by the assistant standing on the right side when necessary. The patient was discharged in good condition on the 23th postoperative day.

Implantation of VVI pacemaker in a patient with dextrocardia, persistent left superior vena cava, and sick sinus syndrome: A case report

BACKGROUND

Dextrocardia, or right-lying heart, is an uncommon congenital heart disease in which the apex of the heart is located on the right side of chest. Persistent left superior vena cava (PLSVA) is a rare venous anomaly that is often associated with the abnormalities of cardiac transduction system. A case with combination of dextrocardia, persistent left superior vena cava, and sick sinus syndrome has not been reported.

METHODS

We used different techniques including cardiac color Doppler echocardiography, 24-hour Holter monitoring, and abdominal ultrasound to make a diagnosis and treated the patient by implanting a VVI pacemaker.

RESULTS

A 50-year-old woman was admitted with a syncope. Angiography of the right atrium and superior vena cava, echocardiography, electrocardiography, and abdominal ultrasound revealed the presence of the combination of mirror image dextrocardia, PLSVA, and sick sinus syndrome. The complex structural anomalies presented great technical challenges for interventional treatments. After thorough examination and understanding of the structural anatomy and anomalies of the superior and inferior vena cava and cardiac chambers, we successfully treated this patient by implanting a VVI pacemaker.

CONCLUSION

Physicians must be aware of the complexity of the morphological and anatomical structures of dextrocardia accompanying PLSVC. Given that the diagnosis of situs inversus was performed at a relatively advanced age, it is therefore important to make such a correct diagnosis followed by appropriate therapeutic intervention.

Platypnea-Orthodeoxia Syndrome: To Shunt or Not to Shunt, That is the Question

Platypnea-orthodeoxia syndrome is a rare disease defined by dyspnea and deoxygenation, induced by an upright position, and relieved by recumbency. Causes include shunting through a patent foramen ovale and pulmonary arteriovenous malformations. A 79-year-old woman experienced 2 syncopal episodes at rest and presented at another hospital. In the emergency department, she was hypoxic, needing 6 L/min of oxygen. Her chest radiograph showed nothing unusual. Transthoracic echocardiograms with saline microcavitation evaluation were mildly positive early after agitated-saline administration, suggesting intracardiac shunting. She was then transferred to our center. Right-sided heart catheterization revealed no oximetric evidence of intracardiac shunting while the patient was supine and had a low right atrial pressure. However, her oxygen saturation dropped to 78% when she sat up. Repeat transthoracic echocardiography while sitting revealed a dramatically positive early saline microcavitation-uptake into the left side of the heart. Transesophageal echocardiograms showed a patent foramen ovale, with right-to-left shunting highly dependent upon body position. The patient underwent successful percutaneous patent foramen ovale closure, and her oxygen supplementation was suspended. In patients with unexplained or transient hypoxemia in which a cardiac cause is suspected, it is important to evaluate shunting in both the recumbent and upright positions. In this syndrome, elevated right atrial pressure is not necessary for significant right-to-left shunting. Percutaneous closure, if feasible, is first-line therapy in these patients.

Modified Senning Procedure for Correction of Atrioventricular Discordance With Total Anomalous Pulmonary Venous Return, Atrial Situs Inversus, Dextrocardia, and Bilateral Superior Venae Cavae

The Senning and Mustard baffles remain important techniques for the treatment of congenitally corrected transposition (cc-TGA), isolated ventricular inversion, and D-transposition of the great arteries with delayed presentation. We describe the treatment of an 8-month old infant with atrioventricular discordance, ventriculoarterial concordance, and dextrocardia with atrial situs inversus. A modified Senning procedure was performed through the "left-sided" atrium. Modifications of the Senning and Mustard baffles remain important tools in the treatment of rare conditions like isolated ventricular inversion.

[Maze procedure in a case of dextrocardia with atrial septal defect and persistent left superior vena cava]

A 52-year-old man was diagnosed with dextrocardia at the age of 1 year and was asymptomatic until 1 year before admission. He was transferred to our hospital for management of atrial fibrillation. A transthoracic echocardiogram showed dextrocardia with atrial septal defect;moderate tricuspid valve regurgitation; and a large, persistent left superior vena cava. A cardiac catheterization study revealed that pulmonary flow/systemic flow (Qp/Qs) was 3.6 and that pulmonary vascular resistance was 2.5 Wood U·m². Intracardiac repair with tricuspid annuloplasty and a maze procedure was scheduled. When establishing cardiopulmonary bypass, venous drainage was initially obtained from the inferior vena cava and the left superior vena cava, and the small superior vena cava was then directly cannulated after opening the right atrium. The patient's postoperative course was uneventful, and serial electrocardiograms have demonstrated maintenance of normal sinus rhythm for 3.5 years after the operation.

[Scimitar syndrome in infancy]

OBJECTIVE

To expose our 26 year experience in clinical management, interventional catheterization and surgical treatment of patients younger than 18 years with scimitar syndrome at the National Cardiology Institute.

MATERIAL AND METHODS

We reviewed retrospectively all patients with scimitar syndrome in infancy between 1984 and 2010. Patients were divided in two groups: younger an older than one year at the time of the diagnosis. Medical records were analized, as well as chest radiography, electrocardiogram, echocardiogram and helicoidal tomography. All therapeutic procedures performed and their outcomes were analized.

RESULTS

We studied 22 patients with scimitar syndrome, 20 of them with associated congenital heart disease. Congestive heart failure (p > or = 0.0001) and severe pulmonary hypertension (p > or = 0.002) were more frequent in patients younger than one year. We documented dextroposition and right lung hypoplasia in 14 patients, and aorto-pulmonary collateral arteries in 15 of them. Pulmonary hypertension was an important mortality risk factor (p > or = 0.007).

CONCLUSIONS

Congestive heart failure and pulmonary hypertension are more frequent in patients younger than one year, and the former is a mortality risk factor. It is important to suspect this congenital heart disease in infants with dextroposition and congestive heart failure in order to provide an opportune treatment.

Successful right coronary artery drug-eluting stent implantation in a male patient with situs inversus

We describe a case of successful right coronary artery angioplasty in a male subject with situs inversus. Although the interventional management of such individuals follows the standard general rules, there are also some technical aspects that should be taken into consideration in this special clinical setting.

Late right pulmonary artery stenosis after arterial switch operation in mirror image dextrocardia and situs inversus totalis

The operation of D-transposition of the great arteries is performed extremely rarely in patients with mirror image dextrocardia and situs inversus totalis. Therefore, it is not surprising that such unusual anatomy case presents problems with primary operation. We present a case of late right pulmonary artery stenosis after neonatal surgical anatomic correction of mirror image dextrocardia and situs inversus totalis.

Two-stent telescoping technique for securing an atrially embolized venous stent

Coronary sinus stenosis or atresia is a rare problem in congenital heart disease. It is sometimes associated with ventricular dysfunction. In this setting, relief of the obstruction may improve myocardial perfusion and contractility. During percutaneous stent deployment within the coronary sinus, distal embolization of the stent into the atrial chambers occurred. The patient had double inlet left ventricle, severe ventricular dysfunction, interrupted IVC, mechanical aortic valve, and a Fontan circulation. The intervention was performed as a rescue procedure prior to transplantation referral. In this report we describe use of telescoping technique, i.e., deploying the distal end of a long stent within the embolized stent while traversing its proximal end across the stenosed coronary sinus ostium. This secured the embolized stent and at the same time relieved the coronary sinus stenosis.

Left atrial isomerism: biventricular repair

OBJECTIVE

Biventricular repair of hearts with left atrial isomerism often necessitates complex atrial and ventricular baffle procedures. We analysed our experience with an accent on baffle techniques.

METHODS

From 1997 until 2008, 12 patients (four male) with left atrial isomerism received biventricular repair. Their median age at surgery was 9 (range: 1-24) months. Four patients had dextrocardia. Nine patients presented with left superior vena cava, three with absent right superior vena cava, five with unroofed coronary sinus and nine others with inferior vena cava interruption with (hemi)azygos continuation. Anomalous pulmonary venous drainage was present in three patients. Eight had a monoatrium. Atrioventricular septal defect (AVSD) occurred in six (complete AVSD in two), One patient with complete AVSD had right pulmonary agenesia with long segment tracheal stenosis. Multiple VSDs presented in one whereas three patients had double-outlet right ventricle (DORV) (one with borderline LV hypoplasia). Two had previous pulmonary artery banding. Complex intra-atrial baffle constructions were performed in seven patients. Complete AVSDs were corrected using two patches and all other AVSDs had one patch repair. Multiple VSDs were closed directly. DORV patients had intraventricular tunnel repair.

RESULTS

No early mortality occurred. Median follow-up was 54 (range: 2-134) months. One patient with complete AVSD and pulmonary agenesia died late after tracheal repair. Four patients needed five re-operations (closure of residual ASD (one), relief of left (two) or right (two) ventricular outflow obstruction, pulmonary artery branch plasty (one)). There was no atrial baffle stenosis. Four received a pacemaker. All survivors are in NYHA class I.

CONCLUSIONS

Survival and functional status of left isomerism patients after biventricular repair is good. Complex repairs with atrial or ventricular baffles are frequent. Arrhythmias were common and pose a concern late after repair.

[Laparoscopic cholecystectomy in situs viscerum inversus totalis: technical note]

The Authors report the case of a patient admitted in Emergency Room for biliary colic. She knew her dextrocardia. ECG and chest X-ray confirmed the dextrocardia. Ultrasonography and CT scan discovered a situs viscerum inversus totalis and cholecystolithiasis responsible of the abdominal colic. Laparoscopic cholecystectomy was performed. The Authors discuss the clinical case and the particular technique used.

Off-pump coronary artery bypass surgery in dextrocardia: a report of two cases

Dextrocardia is a rare condition that may be congenital (situs inversus) or acquired (pseudodextrocardia). Since individuals with this ailment have normal cardiac physiology and function, they may live normal lives. Similar to the general population, however, they might be susceptible to ischemic heart disease and present to a cardiothoracic surgical department for coronary artery bypass surgery. We report two cases: one of dextrocardia (situs inversus) and another resulting from an elevation of the left hemidiaphragm, causing pseudodextrocardia. To operate on patients with dextrocardia, surgeons may need to make a few modifications. These include using the right internal mammary artery as a conduit for the "left" anterior descending artery, lengthening the left internal mammary artery to reach the left anterior descending artery, and sometimes the operating surgeon may need to stand at the left side of the operating table. The careful planning of work on the conduits in the preoperative period requires prudence. This report highlights the surgical difficulties during operations on patients with situs inversus or pseudodextrocardia.

Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis

We report an extremely rare cause of elevated jugular venous pulse where two esoteric causes for the same-cardiac volvulus and cardiac herniation have occurred together. Echocardiographic evidence for making the diagnosis of cardiac volvulus--subcostal long axis, subcostal short axis, and suprasternal views--have been presented. Awareness of this complication is necessary as immediate intervention is mandatory for a positive outcome.

Congenitally Corrected Transposition of the Great Arteries: Surgical Repair in Adulthood

We report a patient with congenitally corrected transposition of the great arteries, dextrocardia in congestive heart failure, with severe tricuspid regurgitation; a large ventricular septal defect, and giant left atrium. The patient underwent a two-ventricle repair with physiologic correction and had an excellent postoperative outcome.

[A neonate with the heart in the right hemithorax]

Three neonates presented with the heart in the right hemithorax: a newborn girl with a chest deformity and secondary dextrocardia (Poland sequence), a prematurely born girl with uncomplicated Kartagener's syndrome, and a newborn boy with cyanosis and the heart in the right hemithorax, in whom a surgical correction was indicated. A diagnosis ofdextrocardia should include the differentiation between primary and secondary dextrocardia. Secondary dextrocardia, or dextroposition, is the result of chest deformities, diaphragmatic defects, severe lung disease, or the presence of a mass displacing the heart from its normal position, usually without any cardiac abnormalities. In primary dextrocardia, the position of the organs in the abdomen is important for the differential diagnosis and the prognosis. The incidence of congenital cardiac malformations in primary dextrocardia varies from 10%, in situs inversus totalis, up to 90% in solitary dextrocardia.

Off-pump myocardial revascularisation in an octogenarian patient with dextrocardia and situs inversus

Dextrocardia associated with situs inversus totalis is a rare condition and there are few reports of myocardial revascularisation in such patients. An 82-year-old woman with dextrocardia and situs inversus totalis underwent successful off-pump coronary artery bypass grafting using internal mammary arteries. The operative technique was similar to that of off-pump coronary artery bypass grafting for situs solitus. However, for a right-handed surgeon the operation was easier standing on the left side of the patient.

Extracardiac Fontan procedure bridging the vertebra for apico-caval juxtaposition

For 5 patients with univentricular heart associated with apico-caval juxtaposition, an extracardiac Fontan procedure was carried out using an artificial graft bridging the vertebra to avoid graft compression by the vertebra and the ventricle. For 2 patients representing nonconfluency between the inferior caval vein and the hepatic vein, a hand-made, shoe-tree graft was used. Postoperatively all patients are doing well without a stenotic venous pathway. This extracardiac operation using an artificial graft bridging the vertebra may be advantageous for univentricular heart associated with apico-caval juxtaposition to prevent a postoperative stenotic venous pathway.

[Anatomic correction of the congenitally corrected transposition of the great vessels by the first successful "double switch" operation in Hungary]

Congenitally corrected transposition of the great arteries is a rare defect characterized by discordant atrioventricular and ventriculoarterial connections. Symptoms result from one or a combination of associated cardiovascular malformations, including ventricular septal defect, pulmonary stenosis or atresia, tricuspid valve dysfunction, dextrocardia, hypoplastic left or right ventricle. Correcting exclusively the associated defects, leaving the morphologic right ventricle in systemic position, will determine the patient's life-long prognosis. Anatomic repair by double switch technique may improve survival of patients with congenitally corrected transposition of the great arteries by establishing the morphologic left ventricle in the systemic circulation. A 3-year-old girl with congenitally corrected transposition of the great arteries, ventricular septal defect, hypoplastic right ventricle, and previous palliative procedure was corrected by double switch technique and patch closure of ventricular septal defect. The authors prefer the double switch procedure inspite of its many surgical challenges because it has very good long-term outcome. The more simple surgery namely the operation of only associated cardiac defects will involve the possibility of deterioration of right ventricular function.

Arterial switch operation for a complex transposition of the great arteries in dextrocardia

A very rare case of a newborn with dextrocardia, complete transposition of the great arteries {S,D,D}, ventricular septal defect, aortic arch hypoplasia, juxtaposition of the morphologically right atrial appendage and superoinferior ventricles is herein presented. He successfully underwent arterial switch operation, ventricular septal defect closure and aortic arch reconstruction with end to end extended direct anastomosis.

Diagnosis of isolated dextrocardia using angiocardiography or surgery

BACKGROUND

Isolated dextrocardia is a rare phenomenon and usually associated with multiple cardiac anomalies. This study was to evaluate the accuracy of diagnosis of isolated dextrocardia by using angiocardiography and to compare it with the results of surgery.

METHODS

The clinical data of 27 cases of congenital isolated dextrocardia were collected to understand the diagnostic approaches to the major cardiac anomalies. All cases underwent angiocardiography followed by palliative or curative surgery. The diagnosis was compared by angiocardiography relying on segmental analysis with the pathological features observed in surgery.

RESULTS

The results of angiocardiography of 22 patients were the same as the pathological features observed during surgery, including one case with congenital left ventricular diverticulum was inadvertently omitted in angiocardiograhy. There were significantly dissimilar diagnoses between angiocardiograhy and post-operation in 5 patients, including anatomical corrected transposition of great arteries misinterpreted as corrected transposition of the great arteries in 1, complete transposition of great arteries misinterpreted as corrected transposition of the great arteries in 1, single ventricle misinterpreted as double-outlet right ventricle in 1, and anatomical double-outlet left ventricle misinterpreted as corrected transposition of the great arteries in 2. Misdiagnostic rate of angiocardiograhy was almost 20%.

CONCLUSIONS

Angiocardiography is of great significance in the diagnosis and classification of isolated dextrocardia. However, because of the intricacy of cardiac anomalies of isolated dextrocardia, atrial angiography and double oblique projection are needed to improve the accuracy of diagnosis to support surgical treatments.

Total extracardiac cavopulmonary connection: an alternative technique of fenestration

Fenestrating an extracardiac conduit used for total cavopulmonary connection normally requires an additional incision on the right-sided atrium and is time consuming. Herein we describe an alternative technique that may be used to facilitate this process, which consists of creating the fenestration by using part of the atrial incision resulting from the disconnection of the inferior vena cava from the right atrium. The advantages of this technique are avoidance of an extra incision and suture line on the atrium, and the ease of construction. This may be especially useful in patients with heterotaxy syndromes with mesocardia or dextrocardia, in whom the atrial mass is displaced posteriorly and can be difficult to reach. Closure of the fenestration can be easily performed at a later stage in the cardiac catheterization laboratory by using a septal occluding device.

A case of acute aortic dissection type A in a patient with situs inversus

We report a case of acute aortic dissection type A in a patient with situs inversus. A 33-year-old male, complaining of sudden chest pain, visited our institute. Contrast-enhanced computed tomography and echocardiography suggested Stanford type A acute aortic dissection and dextrocardia. Aortic root and ascending aortic replacement were successfully performed. Antegrade brain-isolated extracorporeal circulation was established. The aortic branch arteries were mirror-image reversed. Anatomic positional relationships and presence or absence of concurrent anomalies should be sufficiently investigated preoperatively in patients with dextrocardia. His postoperative course was uneventful and a postoperative computed tomographic scan confirmed a good result.

Rupture of ascending aorta secondary to tuberculous aortitis

Tuberculous aortitis generally develops at the distal aortic arch and the descending aorta that are close to specific groups of mediastinal lymph nodes, but exceptionally it develops in the ascending aorta. We report a case of rupture of the ascending aorta after tuberculous aortitis in a 53-year-old man without a history of tuberculosis or evidence of a primary foci who underwent cardiopulmonary resuscitation due to severe hemoptysis with subsequent cardiac arrest. The tuberculous aortitis associated with rupture of the ascending aorta was treated with surgical resection and in situ graft placement.

[Primary coronary angioplasty with stent implantation in a patient with dextrocardia - a case report]

A case of a 45-year-old male with acute myocardial infarction and dextrocardia is presented. The patient underwent successful primary coronary angioplasty with direct stenting. Difficulties in establishing diagnosis and treating patients with dextrocardia and chest pain are discussed.

Transcatheter closure of perimembranous ventricular septal defect in a patient with situs inversus and dextrocardia

Successful transcatheter closure of a perimembranous ventricular septal defect with an Amplatzer device has been reported in patients with levocardia. We report a case in which the device could be deployed successfully in a child with isolated perimembranous ventricular septal defect with situs inversus and dextrocardia.

Anatomic correction for corrected transposition after pulmonary unifocalization

A Senning plus Rastelli operation was performed in a patient who had a rare combination of congenitally corrected transposition of the great arteries (S,L,L) with dextrocardia, major aortopulmonary collaterals, and diminutive central pulmonary arteries with arborization defects. The patient required four preparatory operations including bilateral unifocalizations of the aortopulmonary artery collaterals. Pulmonary artery to systemic pressure ratio after the double switch operation was 0.6. The patient demonstrates good biventricular function on echocardiogram at 3 months after the operation.

Transhepatic closure of a post-fontan hepatic veins to left atrium fenestration in visceral heterotaxia and dextrocardia

This article reports on the transhepatic closure of post-Fontan hepatic veins to left atrium fenestration in a 13-year-old girl with left atrial isomerism, dextrocardia, azygos continuation to the left superior vena cava, and median liver. The transhepatic route seemed to be the less tortuous access to the fenestration which was previously partially occluded with a CardioSeal device. The hepatic veins were entered at the left abdominal side using fluoroscopic guidance and the fenestration was uneventfully occluded with an Amplatzer septal occluder device.

Diagnosis and surgical treatment of congenital dextrocardia

OBJECTIVE

To understand the pathological features of congenital dextrocardia and explore its diagnosis and surgical treatment.

METHOD

The clinical data from 32 cases of congenital dextrocardia were collected to understand the major cardiac anomalies and evaluate the diagnostic approaches of this disease. Analysis of the effect of surgical treatment was also conducted in 16 among the 32 cases.

RESULTS

Complex anomalies such as transposition of great artery (TGA), single ventricle (SV), common trunk (CMT) formation for the arteries were found in 8 out of 13 mirror-image dextrocardia cases, most of the dextroversion (DV) accompanied by physiological correction of the TGA (C-TGA, 11/17) which often involved ventricle septal defect (VSD) and pulmonary stenosis (PS, 8/11). Another 2 cases diagnosed as isolated dextrocardia (IDC) also suffered TGA combined with complete atrioventricular canal (CAVC) defect. Definite diagnoses of dextrocardia (DC) were derived from X-ray examination, including thoracic-abdominal plain X-ray film, hilar computed tomography, high kV chest plain film or ultrafast CT, echocardiogram and angiography. Fontan operation was performed in 8 cases and anatomical correction in 7 with surgical exploration in 1 case. Thirteen patients survived, among whom 8 had complex cardiac defect and 5 of them received modified Fontan operation or total cavopulmonary connection (TCPC).

CONCLUSIONS

Complex cardiac anomalies are not rare in mirror-image dextrocardia, and dextroversion and isolated dextrocardia were usually related to C-TGA+VSD+PS and TGA+CAVC respectively. X-ray examinations are of great significance in the diagnoses and classification of dextrocardia, and echocardiogram and ultrafast CT constitute the major modalities for clarifying intracardial defect and surgical indications. Fontan operations, including modified Fontan and total cavopulmonary connection, might be hopeful surgical treatment for complex congenital heart disease when indications are carefully evaluated.

[Dextrocardia with situ solitus, ventricular loop, double outlet hypoplastic right ventricle and L-malposition of the great arteries. Description and surgical treatment of a rare and complex cardiopathy]

Despite the cardiac surgery improvements allowing the correction of the majority of congenital heart diseases with ventricle-great vessels discontinuity, some abnormalities increase the risk of bi-ventricular reparation. We herein report the case of a patient presenting a rare form of double outlet right ventricle with a ventricular loop, with moderate right ventricle hypoplasia. L-malposition of great vessels and pulmonary artery stenosis, and for whom we opted for a palliative surgical treatment including a systemic-pulmonary anastomosis followed by a upper right bi-directional cavo-pulmonary derivation. The last surgery was followed by recurrent right pleural effusions disappearing after the embolization of the systemic-pulmonary anastomosis by catheterism as it probably obstructed the draining of the cavo-pulmonary anastomosis. The relevance of this clinical case reported is, firstly the description of this ventricle loop resulted from a marked ventricular malposition which is a rare heart disease, and secondly the discussion about the surgical treatment, especially about the choice between palliative and curative surgery. Only comparative studies on long term morbidity and mortality between the bi-ventricular reparation and mono-ventricular palliation will allow the selection of the most appropriate surgical treatment.

"Masked" pulmonary venous obstruction in patients with isomerism of the right atrial appendages: an overstated association

Isomerism of the right atrial appendages is associated with anomalies of pulmonary venous return, which may be obstructive. The associated pulmonary arterial obstruction, however, has been reported to "mask" the pulmonary venous obstruction, with resultant pulmonary edema following augmentation of the flow of blood to the lungs. We postulated that the frequency of "masked" pulmonary venous obstruction has been over-reported in the literature. To ascertain the true situation, we evaluated the frequency of "masked" pulmonary venous obstruction in a large, unselected, group of patients with isomerism of the right atrial appendages. We evaluated the clinical, anatomic, and radiographic data of 65 newborns seen with this syndrome since 1970. Development of pulmonary venous obstruction, both before and after systemic-to-pulmonary shunting and/or infusion of prostaglandin E1, was determined and correlated to clinical and radiographic findings. Of the 65 patients, 19 (29%) were ultimately diagnosed with pulmonary venous obstruction. The pulmonary veins themselves connected in infradiaphragmatic fashion in 10 patients, supracardiac in 3, to the atriums directly in 1, and in mixed fashion in the other 5. Pulmonary venous obstruction was readily apparent in 15 of the 19, as demonstrated by pulmonary edema on initial chest radiography. The remaining four cases ultimately diagnosed with pulmonary venous obstruction received augmentation of pulmonary blood flow with resultant pulmonary edema. Of these four severely cyanosed patients, pulmonary vascular markings on the initial chest radiograph had been normal in one but increased in three. Due to the presence of these clinical markers, they do not truly represent "masked" pulmonary venous obstruction. Except for two patients with minimally obstructed pulmonary arterial blood flow, 44 patients without pulmonary venous obstruction had normal or decreased pulmonary vascular markings at presentation. Of these 44, 14 received infusions of prostaglandin E1, with none developing pulmonary edema. We conclude that pulmonary venous obstruction is usually readily apparent at time of presentation in patients with right isomerism, and that "masked" pulmonary venous is a very rare event which has been over-emphasized in the literature. Careful evaluation of clinical and radiographic findings at time of presentation can correctly identify pulmonary venous obstruction in such patients.

Situs inversus and coronary artery disease

Situs inversus is a rare condition and there are few reports of myocardial revascularization in such patients. A 56-year-old woman with situs inversus totalis and coronary artery disease underwent successful anastomosis of the right internal mammary artery to the anterior descending coronary artery, and a saphenous vein graft to the right coronary artery.