Double Valve Replacement and Tricuspid Annuloplasty in a Patient With Dextrocardia Due To Rheumatic Heart Disease.

Dextrocardia is a rare congenital cardiac anomaly with the heart in the right side of the chest which can often be associated with other complex congenital heart diseases. A 30 year old male presented to our department with dyspnea on exertion NYHA grade IV. The 2D-ECHO showed dextrocardia, rheumatic heart disease with severe mitral stenosis, severe aortic stenosis and severe tricuspid regurgitation. The patient was stabilized and was posted for double valve replacement surgery with tricuspid annuloplasty. As compared to the routine positioning of the patient and CPB machine where the CPB machine is usually on the left side of the patient we chose to place the CPB machine on the right side of the patient, while the operating surgeon operated from the left. A standard median sternotomy was done. We applied the chest spreader in the reverse fashion such that the attachment of the Cooley's retractor was on the right side. Standard aortic and bicaval purse strings were taken and heparin was administered as per institutional protocol. After complete heparinization the aortic cannula was inserted and similarly superior vena cava and inferior vena cava cannulation was also done. Total cardiopulmonary bypass was initiated. Cross clamp was applied in the routine fashion. Patient was administered cold antegrade Del Nido cardioplegia and the heart was arrested. The left atrium was stabbed and the heart was vented from left atrium. The patient was cooled and moderate hypothermia was achieved. Topical ice slurry was added for myocardial protection. An oblique aortotomy was done, starting with a transverse incision situated right above the right coronary cusp. We extended this incision through the Sino-tubular junction into the non-coronary cusp. After the aortotomy was done, the aortic valve was examined. The aortic valve was extremely stenosed with severe calcification of all the three cusps. Valve excision was performed one cusp at a time. We started at the commissure between the right coronary cusp and the non-coronary cusp. We began with the excision of the right coronary cusp which was followed by the left coronary cusp and the non-coronary cusp. The left atrium was incised lateral to the inter-atrial groove of Sondergaard and the mitral valve was evaluated. The mitral valve was severely stenosed with severe calcification on both anterior and posterior mitral leaflets. A mitral valve replacement surgery was done with bileaflet metallic valve prosthesis after the excision of anterior mitral leaflet preserving the posterior mitral leaflet. The aortic valve was sized and the aortic valve was replaced with a bileaflet metallic prosthesis. The right atrium was incised parallel to the AV groove to inspect the tricuspid valve. Tricuspid valve annuloplasty was done in view of dilated tricuspid annulus and severe tricuspid regurgitation. All cardiotomy sites were closed in the standard manner and the patient was weaned off cardio-pulmonary bypass. Standard closure of the chest was done with mediastinal and pleural drains and the patient was shifted in the post-op recovery room in normal sinus rhythm and stable hemodynamics.