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 38-year-old male presented with left-sided hydrocele and indirect inguinal hernia of long duration. His medical history included repeated upper respiratory tract infection requiring frequent hospitalization in childhood and was diagnosed to have a ventricular septal defect (VSD) and situs inversus at the age of 7 years. On examination, the apical impulse was felt in right 5th intercostal space with right precordial bulge. A holosystolic murmur (Grade 3/6) was heard in the right 2-4th intercostal spaces with a loud P2 and normal vesicular breath sounds. The hemoglobin of 16.3 g/dl and platelets of 2,30,000/mm3 were noted on blood investigations. Chest X-ray showed dextrocardia and a right-sided “stomach bubble” []. Situs inversus of abdominal organs was seen on the ultrasound. Echocardiogram (ECHO) revealed dextrocardia, subaortic VSD, mildly dilated right ventricle and atrium, moderate tricuspid regurgitation, and pulmonary arterial hypertension (60 mmHg). ECG was consistent with mirror image dextrocardia.\nA combined spinal epidural anesthesia (CSEA) was planned for hernioplasty and hydrocelectomy. The patient was premedicated with pantoprazole and ondansetron on the morning of surgery. A 20G arterial line was secured for invasive pressure monitoring. Continuous ECG, invasive blood pressure, and pulse oximeter was instituted. With strict asepsis and the patient in sitting position, an 18-gauge epidural catheter was placed at L1-L2 interspace. Using a 25-gauge spinal needle, subarachnoid block was performed with 1.8 ml of 0.5% bupivacaine and 25 μg fentanyl at L3-L4 interspace. The patient's heart rate, blood pressure, and oxygen saturation remained stable during the intraoperative period. Fentanyl 50 μg and graded doses of 0.2% Ropivacaine was administered epidurally to achieve segmental anesthesia for the subsequent operative period. Further intraoperative course was uneventful. In the first 24 hours postoperatively, patient was monitored in the ICU. Buprenorphine 120 mcg twice daily was administered for epidural analgesia. Further postoperative period was uneventful and subsequently, the patient was discharged home.