Case report
A 67-year-old woman presented to the emergency room with progressive dyspnea on exertion for 5 months with worsening of symptoms in the last 3 days, with the onset of orthopnea, paroxysmal nocturnal dyspnea and lower limb edema. She had a history of dextrocardia with situs inversus totalis and aortic valve replacement surgery, ten years previously. Her vital parameters were normal, with bibasal crackling sounds in the lungs and a grade 4 sisto-diastolic murmur in the right paraesternal area at the 2nd intercostal space.
The chest radiography showed a right-sided cardiac shadow with mild cardiomegaly and signs of pulmonary congestion (Figure 1A). Transthoracic ecocardiography revealed dextrocardia, situs inversus, aortic bioprosthetic valve dysfunction due to severe regurgitation and moderate stenosis (mean pressure gradient of 39 mmHg), and a left ventricular ejection fraction of 55%. Computed tomography (CT) demonstrated situs inversus totalis with dextrocardia and no structures identified to be adherent to the sternum (Figure 1B). After completing preoperative assessment and planning, an urgent surgery was indicated.
Surgery was carried out via a median resternotomy. Femoral vessels were exposed in case urgent use of cardiopulmonary bypass became necessary. After sternal reentry, the adhesions between the posterior table and the mediastinal structures were easily divided and pleural spaces were opened bilaterally. Subsequently, dissection of the heart and great vessels was performed without any injury (Figure 2).
The cardiopulmonary bypass (CPB) was established by cannulating the ascending aorta, the superior vena cava, and the inferior vena cava. After aortic cannulation, our operative strategy was to change the position of the main surgeon to the left side of the patient to cannulate both cavas and to perform further surgical steps. Moderate hypothermia was applied. The aorta was cross-clamped, aortotomy was done, and then direct ostial cold blood cardioplegic solution was delivered. The aortic bioprosthesis was found to be calcified and it was carefully removed using an annular preserving technique. A bioprosthesis was implanted using interrupted 2-0 polyester mattress sutures (Figure 3). Interestingly, the direction of taking sutures also changed (forehand bites became backhand and vice versa). The aorta was closed and de-airing was carried. The patient was weaned from CPB and came off in sinus rhythm. The postoperative recovery was uneventful.