Although dextrocardia can be associated with situs
solitus, situs inversus or situs ambiguous, situs solitus
is the most common form.[
4] Situs inversus totalis, as
in our case, is a reverse isomeric form of the thoracic
and abdominal viscera or complete mirror image. Such
patients may have an interrupted inferior vena cava in
the intrahepatic segment. These abnormalities may
cause problems during the inferior venous cannulation.
Therefore, inferior vena cava abnormalities should
be definitely examined by computed tomography or
magnetic resonance imaging.
To date, several approaches for mitral valve surgery
in dextrocardiac patients have been published. As in
our case, almost all surgeons prefer to stand on the
left side of the patient. St. Rammos et al.[5] established
cardiopulmonary bypass by cannulating the aorta and
left common femoral vein. The superior vena cava
was cannulated after emptying the heart. Okamura et
al.[6] lifted the heart by using a heart positioner and
then made bicaval venous cannulation and the aorta
was cannulated in the routine manner. The mitral
valve was exposed via left-sided left atriotomy with an
incision made at the base of the left atrial appendage
similar to our approach, with the surgeon standing
on the left side. However, lifting the heart for
inferior vena cava decannulation while a mitral valve prosthesis is in situ is fraught with danger of the left
ventricular rupture.[7] In another study, Kikon et al.[8]
used a two-stage single venous cannula and performed
left atriotomy. This method may lead to obstruction
of the superior vena cava during the traction to the
left atrium.
Furthermore, we established cardiopulmonary
bypass by cannulating the aorta and superior and inferior
vena cava separately without using any heart positioner
for lifting the heart, since we performed cannulation
by widely separating vena cava superior and inferior
from the pericardium. This may be a technical trick
for safe bicaval cannulation in dextrocardiac patients.
We approached the mitral valve via left atriotomy. We
provided excellent exposure with a little traction. Of
note, although there are few bleeding complications
with the transseptal approach, the extension of the
septal incision to the anterior of the coronary sinus
may lead to nodal rhythm.[9] The other concern is
probability of damaging the sinus node artery in the
superior septal approach. Therefore, we avoided risk
of groove tear during decannulation in mitral valve
replacement by not lifting the heart. We also abstained
superior venous obstruction and rhythm problems by
bicaval venous cannulation and left atriotomy.
In conclusion, we suggest that standing on the
left side of the patient and widely separating the vena
cava inferior and superior from the pericardium for
cannulation and decannulation without lifting the
heart through bicaval venous cannulation and left
atriotomy is more useful approach for the treatment of
dextrocardiac mitral valve.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
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