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.