Aortic Valve Replacement in a Patient with Dextrocardia and Situs Inversus Totalis

Dextrocardia is a congenital cardiac anomaly in which the base-apex cardiac axis points to the right and may be associated to situs solitus, situs inversus, or situs ambiguous. In cases of dextrocardia with situs inversus totalis, the heart and all the other organs are in a mirror image position compared to the normal situation. 

Case Presentation 

The patient is an eighty-six-year-old man with hypertension and dyslipidemia as cardiovascular risk factors. He also has a history of partial prostatectomy due to prostate cancer, cholecystectomy, and atrial fibrillation that was successfully treated with pharmacological therapy. 

The patient consulted because of dyspnea that progressed to functional class III-IV, and his echocardiogram showed severe aortic valve stenosis with an estimated area of 0.7 cm2 and good ventricular function. Importantly, the heart was found to be in a position of dextrocardia. 

An angio-tomography was then performed and showed situs inversus totalis. Given the progression of symptoms, surgery was indicated, and the patient underwent an aortic valve replacement with a biologic valve. A no. 25 prosthesis of bovine pericardium with anticalcification treatment was used. 

The approach employed was an upper ministernotomy to decrease the surgical impact, with the arterial cannula in the ascending aorta and an atriocaval venous cannulation. The position of the surgeon was the usual one, standing at the right side of the patient. 

During the postoperative period, the patient’s course was favorable, with minimal requirement of inotropic drugs. He was transferred to the general ward after forty-eight hours and discharged home the fifth day postsurgery. 

Conclusion 

There are reports in the literature about challenging cases of situs inversus resolved percutaneously with transcatheter aortic valve implantation (TAVI). Although our patient was elderly, he had a low risk assessed with three different scores: STS (3.2), EuroSCORE II (1.3), and ArgenSCORE (2.5). 

As to the approach, there is no significant difference between the minimally invasive technique and conventional surgery regarding overall mortality and postoperative complications. Also, the benefits of the minimally invasive approach have been proven, since it decreases hospitalization time and postoperative pain, as well as the requirement for blood products. 

The few cases published of this rare condition with valve replacement were performed with the main surgeon standing at the left side of the patient (in contrast with the usual position). However, in this case the authors of this article performed the surgery from the right side, the position that the surgeon is used to adopting, thus decreasing the chance of errors. Of note, this was a subjective decision since cases like this are very rarely encountered in cardiovascular practice. 

In conclusion, in the rare case described here, careful planning, choice of a minimally invasive approach and the usual position of the surgeon during the operation, allowed the authors to achieve an excellent surgical result. 

References

1. Shigeaki Aoyagi 1, Satoru Tobinaga 1, Kumiko Wada. Aortic valve replacement for dextrocardia with situs inversus totalis. J Card Surg. 2021 Sep;36(9):3378-3380.
2. Gregory Pattakos, Michael Chrissoheris, Antonios Halapas. Transcatheter Aortic Valve Replacement in a Patient With Dextrocardia and Situs Inversus Totalis. Ann Thorac Surg, 2019 Jan;107(1):e33-e35
3. Nobuyuki Furukawa, Oliver Kuss, Anas Aboud. Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients. Europ Jourl Cardio-Thorac Surg, 2014 Aug;46, (2), 221–227.
4. Salah E. Altarabsheh, Fuad M. Al-Azzam, Salil V. Deo. Left side approach for aortic valve replacement in patient with dextrocardia and situs inversus totalis. J Saudi Heart Assoc. 2017 Oct; 29(4): 297–299.

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