A 76-year-old male with a past medical history of hypertension, hypercholesterolemia, hypothyroidism, chronic obstructive pulmonary disease, diabetes mellitus type two, obstructive sleep apnea, benign prostatic hyperplasia, cerebral vascular accident with residual right-sided weakness, and dextrocardia with situs inversus presented with an abnormal nuclear stress test. Additionally, he had a family history notable for colon cancer and myocardial infarction in his mother and a thrombotic event in his father. He had no history of significant alcohol use, tobacco use, or illicit drug use, and his past surgical interventions were not cardiovascular in nature. He originally presented at an outside hospital following a syncopal event with a 45-second loss of consciousness postmicturition. At the time, he was thought to have orthostatic hypotension, and his tamsulosin was discontinued. He also underwent a nuclear stress test for the syncopal event due to additional complaints of worsening dyspnea on exertion. Nuclear stress testing demonstrated a moderate-sized reversible anterior wall myocardial perfusion defect and a moderate-sized reversible inferolateral wall myocardial perfusion defect. He was transferred to our hospital for further evaluation of symptoms and possible left heart catheterization. Cardiac catheterization revealed the already diagnosed dextrocardia along with a new diagnosis of severe ostial left anterior descending (LAD), mid-LAD, and ostial diagonal coronary artery disease. Transthoracic echocardiography (TTE) showed trace mitral valve regurgitation, mild aortic valve regurgitation, and an ejection fraction of 60%. His underlying dextrocardia with situs inversus caused diagnostic challenge with these tests as his angiographic, radiologic, and echocardiographic images were mirror images of normal cardiac anatomy. Aggressive risk factor modification was initiated, and a consult was placed to cardiothoracic surgery for evaluation for potential coronary artery bypass grafting (CABG). He underwent three-vessel CABG on day 7 of his hospitalization with alterations in management to account for his known dextrocardia with situs inversus. The electrocardiography leads and defibrillator pads were placed in reverse orientation. A left internal jugular vein central venous catheter was placed to provide direct access to the right atrium rather than standard right-sided central venous access. The arterial line was placed in the right radial artery as opposed to the institutional standard left radial artery to accommodate for the position of the surgeon during the operation. Transesophageal echocardiography (TEE) evaluation again confirmed dextrocardia (). To obtain standardly recognized TEE images, the omniplane was adjusted to 180° for the midesophageal four-chamber view. By subtracting 60°, 90°, and 120°, midesophageal midcommissural, two-chamber, and long-axis views were then obtained. Additionally, TEE confirmation of aortic and venous cannulation required turning the probe right for the right-sided aorta and left for liver visualization, respectively. Aside from these alterations in approach, induction, intubation, and anesthetic management were conducted in normal fashion and were uneventful. He remained intubated and was taken to a cardiac intensive care unit postoperatively. A thorough sign-out was given to the intensive care unit staff to ensure understanding of his anatomy and intraoperative course. He was weaned from the ventilator and extubated on postoperative day 1 and transferred to the step-down unit on postoperative day 2. His postoperative course was complicated by urinary retention and an elevation in creatinine that trended down prior to discharge. He was discharged home in stable condition with a urinary catheter in place on postoperative day 6 that was to be removed as an outpatient. Both the patient and the responsible physicians were satisfied with the successful outcome.
A 55-year-old female patient presented to surgical out-patient department (OPD) with chief complaints of pain and left hypochondrium for the last 3 days accompanied by nausea and vomiting. She presented a big dilemma to the attending surgeon as all the clinical signs and symptoms pointed towards symptomatic cholelithiasis, but the pain in the left hypochondrium totally contradicted the diagnosis. It was only with the help of radiological investigation reports that we were able to confirm it as a case of situs inversus totalis. Her chest X-ray typically depicted dextrocardia and spiral computed tomography (CT) scan showed transposition of all major abdominal organs. Echocardiography was carried out and revealed normal cardiac parameters with an ejection fraction of 60%.\nPre-anaesthetic evaluation revealed Mallampatti class II patient with a slight retrognathia, a pulse rate of 74/min, blood pressure of 130/78 mmHg and normal profile of laboratory investigations. She had a history of intermittent respiratory tract infections, especially during the winter season. At present, the patient had no systemic complaint pertaining to any organ system except for the gall bladder disease. A decision to operate the patient was taken and she was posted for open cholecystectomy.\nTablet ranitidine 150 mg and tablet alprazolam 0.25 mg were administered as premedication a night before and 1 h prior to the surgical procedure with a sip of water. In the operation theatre, a good intravenous (IV) access was secured with a wide bore cannula. Induction of anaesthesia was achieved with O2, isoflurane, propofol 120 mg, butorphanol 1 mg and succinylcholine 100 mg. During induction, we encountered masseter spasm immediately after the administration of succinylcholine, which lasted for approximately 45 s, and disappeared spontaneously, but we were able to ventilate the patient with bag and mask during this episode. Intubation was extremely difficult as the larynx was placed quite anteriorly and the laryngoscopic view could be best labelled as Cormack Lehane grade-III. Maintenance of anaesthesia was carried out with injection vecuronium and low concentration of isoflurane in oxygen and nitrous oxide mixture. The peri-operative period was characterized by frequent copious secretions from the respiratory tract that had to be cleared regularly for smooth ventilation. Inj. Hydrocortisone 100 mg was given prophylactically to prevent any bronchospasm. The surgical procedure was smooth and uneventful, and lasted for about 1 h. At the end of surgery, inj. Neostigmine and glycopyrrolate were administered but extubation was delayed as the patient developed prolonged post-operative apnoea. Therefore, extubation was performed only after establishing the return of all protective airway reflexes and establishment of regular breathing pattern. Infiltration of surgical incision site was carried out with 8 ml 0.375% of ropivacaine. The recovery period and hospital stay were uneventful and the patient was discharged in a satisfactory condition on the eighth post-operative day and was called for follow-up after 2 weeks.