Discussion
Dextrocardia is a rare congenital cardiac anomaly where the base-apex
axis of the heart is directed to the right side. The atrial situs can be
situs solitus, situs inversus, or situs ambiguous of which situs
inversus (mirror image dextrocardia) is more common (40%). If all the
visceral organs also get mirrored, then it is called dextrocardia with
situs inversus totalis. In dextrocardia with situs inversus, around 10%
of the cases are associated with other congenital cardiac anomalies
[2].
Our patient had a typical case of dextrocardia with situs inversus
totalis (all visceral organs were mirror images of the normal) and
presented an aortic biological prosthesis dysfunction requiring a redo
aortic valve replacement. The anatomy of the patient is almost
challenging in the case with dextrocardia and decision for the surgeon
where to stand during surgery is crucial.
Some approaches have been described about patients with dextrocardia
with situs inversus totalis for valve replacement but still redo cardiac
surgery is rare. Haldar et al [3] reported a case of aortic and
mitral valve replacement in a patient with dextrocardia and situs
inversus totalis in which they stood on the left side of the patient.
Sahin and colleagues [4] described a transseptal approach for mitral
valve replacement. Saad et al [5] adressed the position of the
surgeon in dextrocardia and situs inversus. Similar to our case,
Altarabsheh et al [6] reported a left side approach for aortic valve
replacement in a patient with dextrocardia and situs inversus, proposing
this operative setting for patients with such unusual anatomy.
A meticulous pre-operative surgical plan involving the whole team was
very important for a smooth intra-operative course and a favourable
outcome. Regarding intraoperative strategy about the position of surgeon
for cannulation and aortic valve approach, we performed bicaval
cannulation, prosthesis removing and new aortic bioprosthesis insertion
with the main surgeon standing on the left side of the patient. We
believed this surgical team arrangement added much to the technical ease
for the surgery, since the anatomy was opposite to what our minds are
used to.
In addition, since it was a redo cardiac surgery with an uncommon
anatomy, CT scan played a crucial role for a proper preoperative
anatomical evaluation of all the great vessels, the heart, possible
associated anomalies and to plan our cannulation strategy. Also, CT scan
permitted to minimize risk of re-entry injury because it could identify
potential adherence of mediastinal structures to the undersurface of the
sternum.
Our patient had dextrocardia with situs inversus totalis requiring a
redo aortic valve surgery. CT scan had an important role for operative
planning, which contributed substantially for the good result of the
operation. Our left side approach provided excellent exposure for redo
aortic valve replacement in this scenario.