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.
The patient is an 86-year-old man, with hypertension and dyslipidemia as cardiovascular risk factors, and a history of partial prostatectomy due to prostate cancer, cholecystectomy, and atrial fibrillation successfully treated with pharmacological therapy.
The patient consulted due to 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 anti-calcification treatment was used.
The approach employed was an upper mini sternotomy 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 post-operative period, the patient’s course was favorable, with minimal requirement of inotropic drugs. He was transferred to the general ward after 48 hours and discharged home the fifth day post surgery.
There are reports in the literature about challenging cases of situs inversus resolved percutaneously with TAVI. Although our patient was elderly, he had a low risk assessed with 3 different scores: STS (3.2), EUROSCORE II (1.3) and ArgenScore (2.5).
As to the approach, there is no significant difference between the mini invasive technique and conventional surgery regarding overall mortality and post-operative complications. Also, the benefits of the mini invasive approach have been proven, since it decreases hospitalization time and post-operative 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 we 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 us to achieve an excellent surgical result.
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