Situs inversus totalis: A challenge for cardiac resynchronization therapy

Situs inversus totalis (SIT) is a congenital condition in which the major visceral organs are reversed or in a mirror image from their normal positions that affects one per 10,000 live births. It is associated with dextrocardia (DXC) in which the heart is located on the right side of the chest. We present a challenging cardiac resynchronization therapy (CRT) implantation in a 60-year-old man with SIT-DXC, heart failure, extreme bradycardia, wide QRS, and left ventricular (LV) dysfunction. The procedure was complex due to the mirror-image anatomy and the tortuous origin of the coronary sinus (CS) branches that required a subselection catheter for adequate lead implantation.

Coronary Artery Bypass Grafting in a Patient With Multivessel Disease and Dextrocardia With Situs Inversus Totalis

Dextrocardia with situs inversus totalis is a rare hereditary condition characterized by reversed orientation of the major thoracic and abdominal organs. Though dextrocardia itself is not believed to increase the risk of coronary artery disease, the workup and surgical management of patients with this condition may be technically challenging to heart team clinicians. This report describes the case management of a high-risk 56-year-old man with dextrocardia who presented with multivessel coronary artery disease.

Congenital hemivertebrae combined with situs inversus totalis: A rare case report

RATIONALE

Situs inversus totalis is a rare malposition of organs that typically involves lesions in the respiratory, circulatory, or urinary systems. Cases of congenital hemivertebrae combined with situs inversus totalis are extremely rare and have limited reports.

PATIENT CONCERNS

We report a 2.5 years old girl with 2 congenital hemipyramids and complete visceral inversion who ultimately underwent hemilaminectomy.

DIAGNOSIS

Congenital hemivertebrae combined with situs inversus totalis.

INTERVENTION

The patient underwent hemilaminectomy.

OUTCOMES

The spinal deformity was corrected.

LESSONS

For patient with spinal deformities combined with situs inversus totalis, surgery can be an effective treatment method. But we also need to be vigilant about the dysfunction of various systems.

Successful Endoscopic Treatment of a Pancreatic Pseudocyst in a Patient with Situs Inversus Totalis and Upper GI Duplication

BACKGROUND Duplication of the gastrointestinal tract is a rare congenital malformation that can develop in any part of the digestive tract. These duplications may be asymptomatic into adult age. Situs inversus totalis is a rare congenital anomaly characterized by a mirror transposition of thoracic and abdominal organs. We present a case of a pancreatic pseudocyst in a patient with a combination of situs inversus totalis and doubling of the esophagus, stomach, and first part of the duodenum. CASE REPORT A 64-year-old woman presented with epigastric pain. Abdominal computed tomography revealed a pancreatic pseudocyst and a previously identified duplication of the esophagus, stomach, and duodenum with situs inversus totalis. The patient underwent esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography for pseudocyst drainage. During EGD, a bifurcation of the esophagus was found. Duplication of the esophagus, stomach, and first part of the duodenum was evident on further advancement. A week later, there was repeated filling of the pseudocyst with a liquid component, and the patient underwent cystogastrostomy with stenting. Five months after discharge, the stent was removed without complications. CONCLUSIONS Duplication of the gastrointestinal tract and situs inversus totalis are very rare congenital malformations that require early diagnosis. While situs inversus totalis does not represent any medical disadvantage, physicians should be aware of abnormal anatomy before procedures to prepare specialists for this in case of the need for special techniques. Endoscopic treatment of pancreatic pseudocysts is safe and effective even in such rare cases. The use of endoscopic methods also minimizes intervention and decreases the length of the patients' stays in the hospital.

A Case of Left-Sided Acute Appendicitis in a 45-Year-Old Man with Situs Inversus Totalis Managed by Emergent Laparoscopic Appendectomy

BACKGROUND Situs inversus totalis (SIT) is a rare congenital abnormality that includes mirror-image transposition of both the abdominal and the thoracic organs. It may remain undetected into adulthood until an acute medical emergency results in diagnostic imaging. This report presents a challenging case of left-sided acute appendicitis in a 45-year-old man with SIT. CASE REPORT A 45-year-old man with a medical history of gastroesophageal reflux disease, class 2 obesity, prediabetes, and elevated low-density lipoprotein cholesterol presented with severe acute abdominal pain localized in the left lower quadrant with localized tenderness, nausea, and 2 episodes of non-bloody and non-bilious emesis that started a day before the clinical encounter. Computed tomography of the abdomen and pelvis revealed previously undiagnosed congenital SIT. In addition, physical, laboratory, and radiological findings suggested early acute appendicitis with no evidence of complications. Hence, the patient was managed with an emergent laparoscopic appendectomy. Acute appendicitis was confirmed in the post-surgery histopathological examination. The post-surgery recovery was uneventful, and the patient was discharged home on the second postoperative day. CONCLUSIONS This report highlights that SIT may remain undiagnosed into adulthood and poses a challenge in the diagnosis of left-side appendicitis due to atypical symptom presentation, supporting the findings of previous case reports. Therefore, the inclusion of left-sided acute appendicitis in the differential diagnosis of abdominal pain in the left lower quadrant is warranted.

Three-dimensional high-definition live tissue virtual dissection of mirror-image dextrocardia with thoracic-abdominal discordance in a fetus

Three-dimensional virtual dissection using high-definition live tissue rendering ultrasound tool of a 23-week gestation fetus with situs solitus, mirror image dextrocardia, ventricular septal defect, aortic override, and pulmonary atresia.

Coronary Angiography and Chronic Total Occlusion Angioplasty in a Patient With Situs Inversus from the Right Radial Approach

We present the case of a patient with known situs inversus referred for cardiac catheterization, which revealed a chronic total occlusion of the right coronary artery. Situs inversus, a rare congenital abnormality, is a term used to describe the inverted position of the chest and abdominal organs. Cardiac catheterization is rare in patients with this particular abnormality. It is important to customize techniques to engage coronary arteries and optimize guide support if percutaneous coronary intervention is required in these particular cases.

Percutaneous coronary intervention for chronic total occlusion of the left circumflex branch in mirror dextrocardia: a case report

BACKGROUND

Mirror dextrocardia (MDC) is a condition in which the heart is located in a mirror-image position on the right side of the chest compared to the normal position in individuals with physiological variations. Patients with MDC and chronic total occlusion (CTO) of the left circumflex branch (LCX) are extremely rare in clinical practice. The treatment of MDC-CTO-LCX differs significantly from patients without mirror dextrocardia and the same condition in terms of instrument selection and procedural techniques. In this article, we report a successful case of interventional treatment in a patient with MDC-CTO-LCX. We summarize the anatomical and electrocardiographic variations in patients with MDC-CTO-LCX, and discuss the selection of interventional instruments and techniques that can be useful for interventionists as well as the diagnostic and therapeutic considerations that can be helpful for clinical physicians.

CASE PRESENTATION

A male Han Chinese patient, 51, was admitted, presenting recurrent chest pain for a year and recent onset of exertional fatigue over the past week.He reported episodes of chest pain following physical activities over the past year, lasting between 5 and 20 min.Despite these symptoms, the patient did not seek immediate medical attention, and the occurrence of his chest pain has progressively lessened within the year.A week prior, the patient developed exertional dyspnea after brief walks, though without any episodes of nocturnal paroxysmal dyspnea.Upon arrival at our hospital for evaluation, he was initially diagnosed with chronic coronary syndrome, previous inferior myocardial infarction, atrial arrhythmia, and classified under the New York Heart Association functional class III.Following his admission, a chest X-ray and coronary angiography were conducted.The results indicated mirror dextrocardia and total occlusion of the left circumflex branch. Percutaneous coronary intervention (PCI) was performed on the left circumflex branch. Subsequent angiography demonstrated optimal stent positioning without evidence of hematoma or dissection.Following the procedure, the patient's symptoms of chest pain and exertional dyspnea were resolved, which led to his subsequent discharge.A follow-up electrocardiogram, 10 months post-procedure, displayed a slow and regular atrial rhythm.

CONCLUSIONS

The incidence of dextrocardia is very low, and it may appear normal on an electrocardiogram; however, careful diagnosis is required when there is an abnormal direction of the P wave in limb leads. During the operation for chronic occlusive lesions of the right-sided coronary artery, the anomalous anatomical structure necessitates specific requirements for instrument selection and operative techniques. After revascularization of chronic occlusive vessels in dextrocardia, routine electrocardiographic examination may show false normalization, requiring caution in interpretation.

Outcomes of the Arterial Switch Operation in Patients With Dextrocardia

BACKGROUND

Patients with dextrocardia and d-transposition of the great arteries (d-TGA) present a technical challenge when performing the arterial switch operation (ASO). We sought to determine the long-term outcomes of this rare presentation.

METHODS

All patients who underwent the ASO with d-TGA and dextrocardia were identified from the hospital database.

RESULTS

There were four patients with dextrocardia (4 of 844, 0.5%) patients; two patients had situs solitus and two patients had situs inversus. Three patients had a ventricular septal defect. Left ventricular outflow tract obstruction was present in one patient and one patient had a hypoplastic arch with severe coarctation of aorta. Anomalous coronary anatomy occurred in two patients. There was one early mortality and the cause of death was sepsis. One patient required late reoperation for severe neo-pulmonary valve regurgitation at 23 years after the ASO. At last follow-up, all three surviving patients were in New York Heart Association Class I.

CONCLUSIONS

Patients with d-TGA and dextrocardia who undergo the ASO are extremely rare and require challenging operative management.

3D TEE imaging in a patient with severe tricuspid regurgitation with dextrocardia and tricuspid commissural prolapse

Although dextrocardia is a rare congenital anomaly, it may be accompanied by numerous pathologies. Tricuspid valve prolapse is an extremely uncommon cause of primary tricuspid valve disease, as is its association with dextrocardia. In this instance, we wished to share our knowledge of tricuspid commissural prolapse together with dextrocardia, which we augmented with 3D images.

Situs inversus with dextrocardia and transposition of great arteries

Transposition of the great arteries with left ventricle outflow tract obstruction in combination with situs inversus totalis and dextrocardia is a very rare anomaly and carries high morbidity and mortality. Only few cases have been reported with this anomaly. We describe a 21-day of infant girl with transposition of the great arteries and mirror image dextrocardia and pulmonary stenosis who underwent successful neonatal arterial switch operation and left ventricle outflow tract obstruction resection following PDA stent implantation.

Cor triatriatum sinister with dextrocardia in association with ostium secundum atrial septal defect, subpulmonary ventricular septal defect and bicuspid pulmonary valve in a pig

Necropsy of a 52-day-old Camborough pig revealed numerous cardiac malformations. The positional relationship of the atria, ventricles and great vessels was a mirror image type (I, L and L): inverted arrangement of the atria, with a left-sided right atrium and right-sided left atrium (situs inversus); inverted arrangement of the ventricles, with a left-sided morphological right ventricle and right-sided morphological left ventricle (L-loop); and aortic valve to the front left relative to the pulmonary valve (L-malposed). The major malformations included an ostium secundum atrial septal defect, cor triatriatum sinister (CTS), a subpulmonary ventricular septal defect and a bicuspid pulmonary valve. Histological examination revealed myocyte hypertrophy, focal myocardial necrosis and calcification in the left morphological right ventricle of the heart. To the best of our knowledge, this is the first report of CTS in pigs. Although the individual malformations found in the present case are not unique, an unusual combination of these cardiac malformations has not been described in animals.

Insertion of a totally implantable vascular access device in a patient with dextrocardia and colon cancer: a case report

Colon cancer in patients with situs inversus totalis is rarely associated with dextrocardia, and chemotherapy is commonly used for treatment. Central venous access devices are used to administer intravenous fluids and chemotherapy in patients with colon cancer. Compared with peripherally inserted central catheters and Hickman-type tunneled catheters, totally implantable vascular access devices (TIVADs) are safer and more effective. However, positioning the catheter tip may be challenging in patients with dextrocardia and situs inversus. We herein describe a novel case involving a patient with dextrocardia and colon cancer who was treated by TIVAD insertion with intracavitary electrocardiography-aided tip localization.

Mitral valve repair in patients with mirror-image dextrocardia and situs inversus: two cases and a review of the literature

Dextrocardia is a rare cardiac malposition that was first described in 1606. Mirror-image dextrocardia is characterized by a mirror-image change of the normal position of the heart. Most cases are accompanied by situs inversus viscerum, whereas only 3% to 10% of cases are associated with intracardiac anomalies. Valve surgery for acquired valvular lesions in patients with mirror-image dextrocardia with situs inversus is rare. Diagnosing situs anomalies in adults is important to prevent errors during surgical operations, emergency procedures, or interventional operations. In this report, we present two cases of mitral regurgitation in patients with mirror-image dextrocardia. One patient had mirror-image dextrocardia with subacute infective endocarditis and mitral regurgitation, and the other patient had mirror-image dextrocardia with mitral Carpentier type I regurgitation. In both patients, mitral valve repair was successfully performed using a transseptal approach.

Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis and a Double Superior Vena Cava

BACKGROUND Situs inversus totalis (SIT) is an uncommon condition characterized as a congenital disorder in which the visceral organs are inverted relative to their typical anatomical position. SIT with double superior vena cava (SVC) is an even rarer presentation. Due to the underlying anatomical difference, the diagnosis and treatment of gallbladder stones in patients with SIT are challenging. CASE REPORT We report the case of a 24-year-old male patient who presented with an intermittent history of epigastric pain for 2 weeks. Clinical assessment and radiological investigations confirmed gall bladder stones with evidence of SIT and double superior vena cava (SVC). The patient underwent elective laparoscopic cholecystectomy (LC) with an inverted laparoscopic approach. The recovery from the operation went smoothly, the patient was discharged from the hospital the following day, and the drain was removed on the third postoperative day. CONCLUSIONS Because anatomical variations in the SIT can affect localization of symptoms in patients with complicated gallbladder stones, the diagnosis of patients who have abdominal pain and SIT necessitates both a high index of suspicion and a thorough assessment. Although LC is considered to be a technically challenging surgery and calls for modification of the standard protocol, it is nevertheless feasible to perform the procedure effectively. To the best of our knowledge, this is the first time that LC has been documented in a patient who has SIT and double SVC.

Implantation of a dual-chamber pacemaker in a patient with dextrocardia and sick sinus syndrome: a case report

Dextrocardia is a congenital abnormal position of the heart in which the main part of the heart is in the right chest, and the long axis of the heart points to the lower right. Cases of a combination of dextrocardia and sick sinus syndrome are rare. A 65-year-old female patient was admitted to hospital with palpitations and dizziness for 1 week. Mirror-image dextrocardia and sick sinus syndrome were diagnosed by an electrocardiogram, echocardiography, Holter monitoring, and X-rays. Finally, we successfully implanted a dual-chamber pacemaker into the patient. The patient had an uneventful recovery and was discharged when her symptoms had greatly improved 1 week later. When dextrocardia is present, using active fixation leads in the atrial and ventricular leads is easier for finding the pacing position with optimal sensing and pacing thresholds, and they reduce the incidence of falling off.

Sinus venosus atrial septal defect and partial anomalous pulmonary venous connection in a patient with dextrocardia

An 85-year-old woman presenting with symptomatic pulmonary hypertension (PH) with a history of dextrocardia was referred to our facility for treatment of heart failure. Significant shunting was detected by measuring oxygen saturation during right heart catheterisation (RHC). CT with contrast revealed sinus venosus atrial septal defect (SVASD) and partial anomalous pulmonary venous connection (PAPVC), in which the left upper and middle lobar pulmonary veins returned to the superior vena cava and right atrium. Despite medical treatment, the patient died, and an autopsy was performed. SVASD and PAPVC are rare congenital anomalies. RHC with measurement of oxygen saturation and CT with contrast should be considered in patients with unexplained right atrial and ventricular enlargement or suspected PH.

Successful percutaneous left atrial appendage occlusion for atrial fibrillation in a patient with mirror-image dextrocardia: a case report

BACKGROUND

Dextrocardia is a rare congenital condition (1/10,000-12,000) and AF is uncommon (1-2%). Therefore, the occurrence of the two conditions is rare. Percutaneous left atrial appendage occlusion (LAAO) is a treatment to prevent atrial fibrillation (AF)-associated thromboembolic events.

CASE PRESENTATION

An 85-year-old female with known situs inversus totalis, persistent AF, and stroke was treated with oral anticoagulation, but she was suffering from constant gingival bleeding. Her CHA2DS2VASc score was 6 points (abnormal, ≥ 2), and her HAS-BLED score was 4 points (abnormal, ≥ 3). The transthoracic echocardiography (TTE) demonstrated left atrial (LA) enlargement (46 mm) and 50% of ejection fraction. She underwent percutaneous LAAO for stroke recurrence prevention using a Watchman occluder. The operation was successful but with technical differences compared with a standard case because of the dextrocardia.

CONCLUSION

This is the first reported case of a percutaneous LAAO in situs inversus dextrocardia. This case indicates the feasibility of LAAO in congenital cardiac malposition combined with AF.

Emergency thrombectomy for cerebrovascular occlusion in a patient with mirror-image dextrocardia: a case report

Cases of patients complicated with dextrocardia who suffer from acute cerebral infarction with large vessel occlusion and receive emergency thrombectomy are particularly rare and have not been widely reported. This article aimed to increase the awareness and knowledge of these cases. We report the case of a patient with mirror-image dextrocardia who suffered from cerebral infarction with large vessel occlusion and received emergency thrombectomy. A male patient in his early 60s with dextrocardia had acute cerebral infarction with posterior circulation large vessel occlusion and underwent emergency thrombectomy. During the operation, the rapid confirmation of dextrocardia and use of flexible interventional instruments helped establish a pathway for blood flow. We used an intracranial thrombectomy stent and intracranial balloon dilation catheter to restore the cerebral blood supply. The Modified Rankin Scale score was 0 at 3 months after thrombectomy, indicating a good prognosis of the patient. Acute cerebral infarction with large vessel occlusion in patients with dextrocardia is extremely rare. Emergency thrombectomy is feasible to recanalize cerebral blood flow and give patients a chance to recover.

Radiofrequency catheter ablation in a patient with dextrocardia, persistent left superior vena cava, and atrioventricular nodal reentrant tachycardia: A case report

RATIONALE

Dextrocardia is a rare congenital heart disease, while the persistent left superior vena cava (PLSVC) is an uncommon congenital vascular malformation. It is extremely rare for a person to have dextrocardia and PLSVC. A case with a combination of dextrocardia, PLSVC, and atrioventricular nodal reentrant tachycardia has not been reported.

PATIENT CONCERNS

A 51-year-old woman was admitted to the hospital with palpitations. The physical examination revealed a heart rate of patient increased significantly, and that apex beating was found in the right fifth intercostal space approximately 0.5 cm from the midclavicular line.

DIAGNOSIS

We used different techniques, including electrocardiography, esophagus heart electrophysiology, chest radiograph, and cardiac color Doppler echocardiography to reveal the presence of the combination of dextrocardia, PLSVC, and supraventricular tachycardia.

INTERVENTIONS

We terminated tachycardia by esophageal pacing and cured patients with radiofrequency catheter ablation (RFCA).

OUTCOMES

The complex structural anomalies presented great technical challenges for interventional treatments. After consulting the literature, thorough examination and understanding of the structural anatomy and anomalies of the vena cava and cardiac chambers, we successfully treated this patient by RFCA. After half a year of follow-up, the patient did not have palpitations, and no arrhythmia was seen on the electrocardiography.

LESSONS

Physicians need to be aware that the key to the success of RFCA, in this case, is to clarify the complexity of the morphological and anatomical structures of dextrocardia accompanying PLSVC and to consult and understand the experience of access vessels reported in relevant cases before the operation.

[Mitral Valve and Tricuspid Valve Regurgitation in a Patient with Dextrocardia and Absence of the Inferior Vena Cava]

Dextrocardia is a rare condition frequently associated with multiple and complex cardiovascular abnormalities. A 66-year-old woman, who had been diagnosed with dextrocardia at young age, was referred to our hospital with complaint of increasing dyspnea. Severe mitral regurgitation, moderate tricuspid regurgitation, and atrial fibrillation were detected. The multi detector-row computed tomography(MDCT) revealed absence of the inferior vena cava, and the hepatic vein connected directly with the right atrium. The venous cannulae were inserted into the superior vena cava directly and into the hepatic vein from the right atrium. Mitral valve repair, tricuspid valve repair, and maze procedure were successfully performed. MDCT is useful for detecting abnormality of vena cava in a cases of dextrocardia.

Transradial Approach to Coronary Angiography and Percutaneous Intervention in Patients With Dextrocardia

Patients with dextrocardia present unique challenges in the catheterization laboratory. Variable coronary artery anatomy impacts percutaneous access, catheter selection and manipulation, and image acquisition. This is a review of all published reports of radial artery access for diagnostic and/or therapeutic coronary interventions in patients with dextrocardia. We conclude that the radial approach is safe and effective in these patients and should be used without hesitation. In addition, interventionalists should consider use of multipurpose catheters and possess an understanding of how mirror-image fluoroscopy impacts catheter manipulation. Furthermore, we propose a stepwise approach to arterial access, fluoroscopy, and catheter selection for operator reference while treating dextrocardia patients.

Dextrocardia with complete AV block and the implantation of a temporary pacemaker before cesarean section: A case report

RATIONALE

Patients with situs inversus totalis (SIT) and complete atrioventricular (AV) block are extremely rare, and only few cases have been reported up to now. Due to the rarity of such condition and its anatomical complexity, we reported this case as a reference for obstetricians, providing valuable insights into potential clinical treatment.

PATIENT CONCERNS

We reported a case of 30-year-old patient with complete AV block, and her heart rate was only about 45 beats per minute.

DIAGNOSES

The patient was diagnosed with term delivery with SIT and complete AV block.

INTERVENTIONS

A temporary pacemaker (TPM) was implanted before cesarean section (CS) because of complete AV block.

OUTCOMES

CS was performed successfully after the implantation of a TPM. The heart rate remained stable, and the 24-hour blood loss was limited.

LESSONS

This study presents a complex heart disease case which needed more frequent antenatal examination and restriction of physical activity. To reduce the risk of pregnancy, basic disease needed to be cured before pregnancy. Our findings could provide guidance for future clinical studies.

Catheter ablation of premature ventricular contractions originating from aortic sinus cusps in a patient with dextrocardia and situs solitus: A case report

BACKGROUND

Premature ventricular contractions (PVCs) originating from aortic sinus cusps is not infrequent and can be eliminated effectively by radiofrequency ablation with rare complications. However, after a review of the medical literature, and to our knowledge, this is the first case of successful idiopathic aortic sinus cusps-PVC-ablation using a 3-dimensional (3D) mapping system in an adult with dextrocardia.

METHODS

A 62-year-old male with dextrocardia and situs inversus underwent catheter ablation of frequent PVCs. The electrocardiograms (ECG) were recorded by placement of the electrodes in reversed positions. The PVCs exhibited left bundle branch block and inferior axis QRS morphology with transition at leads V2-V3. The activation mapping indicated the earliest site of ventricular activation between the left and right aortic sinus cusps, highlighting that catheter ablation was successful at this point.

RESULTS

The catheter ablation was successful between the left and right aortic sinus cusps, and the PVCs were not detected for the subsequent 30 min following the procedure as well as for the rest of the hospital stay.

CONCLUSION

Combined with ECG electrodes in reversed positions and 3D electroanatomical mapping system, catheter ablation of PVCs originating from aortic sinus cusps in patients with dextrocardia can be safely and effectively performed.

Implantation of VVI pacemaker in a patient with dextrocardia, persistent left superior vena cava, and sick sinus syndrome: A case report

BACKGROUND

Dextrocardia, or right-lying heart, is an uncommon congenital heart disease in which the apex of the heart is located on the right side of chest. Persistent left superior vena cava (PLSVA) is a rare venous anomaly that is often associated with the abnormalities of cardiac transduction system. A case with combination of dextrocardia, persistent left superior vena cava, and sick sinus syndrome has not been reported.

METHODS

We used different techniques including cardiac color Doppler echocardiography, 24-hour Holter monitoring, and abdominal ultrasound to make a diagnosis and treated the patient by implanting a VVI pacemaker.

RESULTS

A 50-year-old woman was admitted with a syncope. Angiography of the right atrium and superior vena cava, echocardiography, electrocardiography, and abdominal ultrasound revealed the presence of the combination of mirror image dextrocardia, PLSVA, and sick sinus syndrome. The complex structural anomalies presented great technical challenges for interventional treatments. After thorough examination and understanding of the structural anatomy and anomalies of the superior and inferior vena cava and cardiac chambers, we successfully treated this patient by implanting a VVI pacemaker.

CONCLUSION

Physicians must be aware of the complexity of the morphological and anatomical structures of dextrocardia accompanying PLSVC. Given that the diagnosis of situs inversus was performed at a relatively advanced age, it is therefore important to make such a correct diagnosis followed by appropriate therapeutic intervention.

Diagnostic value of echocardiography in isolated congenital unilateral lung agenesis combined with different anomalies: Two rare cases in children

Unilateral lung agenesis, a rare congenital deformity, is secondary to abnormal embryonic development, leading to a shift of the mediastinum and remaining lung. In our case reports, we describe the diagnostic courses of two pediatric patients with unilateral lung agenesis admitted to our hospital in 2014. We present and compare the findings in transthoracic echocardiography with that in CT. Echocardiography played a pivotal role in revealing pulmonary deformities and leading to the diagnosis. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:514-517, 2016.

Aortic Valve Replacement in Dextrocardia and Anomalous Origin of the Coronary Artery

Situs inversus totalis and anomalous origin of the left coronary artery are rare conditions. An 87-year-old woman with both conditions presented to the authors' hospital with symptomatic aortic stenosis. She underwent aortic valve replacement (AVR) and coronary artery bypass grafting (CABG; saphenous vein graft to the left main trunk). The operator mainly stood on the left side of the patient and performed surgery without difficulty. Both, AVR and CABG were successfully performed despite these two rare conditions. Open-heart surgery in a very elderly patient with both of these rare conditions has not previously been reported.

Platypnea-Orthodeoxia Syndrome: To Shunt or Not to Shunt, That is the Question

Platypnea-orthodeoxia syndrome is a rare disease defined by dyspnea and deoxygenation, induced by an upright position, and relieved by recumbency. Causes include shunting through a patent foramen ovale and pulmonary arteriovenous malformations. A 79-year-old woman experienced 2 syncopal episodes at rest and presented at another hospital. In the emergency department, she was hypoxic, needing 6 L/min of oxygen. Her chest radiograph showed nothing unusual. Transthoracic echocardiograms with saline microcavitation evaluation were mildly positive early after agitated-saline administration, suggesting intracardiac shunting. She was then transferred to our center. Right-sided heart catheterization revealed no oximetric evidence of intracardiac shunting while the patient was supine and had a low right atrial pressure. However, her oxygen saturation dropped to 78% when she sat up. Repeat transthoracic echocardiography while sitting revealed a dramatically positive early saline microcavitation-uptake into the left side of the heart. Transesophageal echocardiograms showed a patent foramen ovale, with right-to-left shunting highly dependent upon body position. The patient underwent successful percutaneous patent foramen ovale closure, and her oxygen supplementation was suspended. In patients with unexplained or transient hypoxemia in which a cardiac cause is suspected, it is important to evaluate shunting in both the recumbent and upright positions. In this syndrome, elevated right atrial pressure is not necessary for significant right-to-left shunting. Percutaneous closure, if feasible, is first-line therapy in these patients.

Modified Senning Procedure for Correction of Atrioventricular Discordance With Total Anomalous Pulmonary Venous Return, Atrial Situs Inversus, Dextrocardia, and Bilateral Superior Venae Cavae

The Senning and Mustard baffles remain important techniques for the treatment of congenitally corrected transposition (cc-TGA), isolated ventricular inversion, and D-transposition of the great arteries with delayed presentation. We describe the treatment of an 8-month old infant with atrioventricular discordance, ventriculoarterial concordance, and dextrocardia with atrial situs inversus. A modified Senning procedure was performed through the "left-sided" atrium. Modifications of the Senning and Mustard baffles remain important tools in the treatment of rare conditions like isolated ventricular inversion.

An adult case of polysplenia syndrome associated with sinus node dysfunction, dextrocardia, and systemic venous anomalies

A 54-year-old woman was referred to our hospital for symptomatic sinus bradyarrhythmia with a sinus pause of 8 seconds. She was diagnosed with dextrocardia during childhood and discovered to have heterotaxy syndrome when she had an appendectomy during her teenager years. Chest and abdominal examinations by computed tomography showed multiple spleens located on the right side and abnormal drainages of the superior and inferior vena cava. Left isomerism was diagnosed by bilaterally bilobed lungs. Because of a patent bilateral superior vena cava, pacemaker leads were implanted using the right cephalic vein approach. Her fainting symptoms disappeared after pacemaker implantation.

Clues to diagnosing carcinoid heart disease as the cause of isolated right-sided heart failure

Described herein is a 67-year-old woman who underwent replacement of both tricuspid and pulmonic valves because of severe isolated right-sided systolic heart failure. The cause of the heart failure preoperatively was believed to be the result of left breast radiation a year earlier. At operation, however, the pulmonic valve was excised and a biopsy of the stiff-walled right atrium was performed, and histologic examination of each was classic of carcinoid heart disease. She never awoke postoperatively. Postoperatively, computed tomography disclosed numerous masses in the liver. Retrospectively, clues to the presence of carcinoid heart disease include thickening of both the tricuspid and pulmonic valve leaflets by echocardiogram, a pressure gradient, albeit small, across the pulmonic valve, the plastering of the septal tricuspid-valve leaflet to the ventricular septum, the total absence of left-sided heart disease, and the presence of extremely low 12-lead QRS electrocardiographic voltage.

Arrhythmia management for the adult patient with congenital heart disease: an update and analytical review

Arrhythmia in the adult congenital heart disease (ACHD) population is recognized as a major source of morbidity and mortality and has contributed to an increasing burden on the health care system over the past several decades. Abnormalities of impulse formation and propagation encountered in this population are distinct from those encountered in the general adult population. Such differences are related to the anatomic variability of congenital heart disease, the resulting postoperative hemodynamic disturbances, and the effects of prior cardiac surgery on the underlying myocardial substrate. Effective arrhythmia therapy in this population therefore requires a detailed understanding of these diverse processes and often results in specialized care at regional centers of excellence. Given the large and evolving body of literature dealing with the treatment of cardiac arrhythmia in the congenital heart population, a coherent picture of arrhythmia treatment and efficacy can be difficult to establish. The existing data is therefore dissected and summarized in this manuscript. In addition, recent expert consensus guidelines for the management of arrhythmia in the ACHD population have been published and will be reviewed in this article, with a special emphasis on unique considerations when treating CHD patients presenting with a disturbance in cardiac rhythm.

Primary ciliary dyskinesia diagnosed by electron microscopy in one case of Kartagener syndrome

Primary ciliary dyskinesia (PCD) is associated with abnormalities in the structure of a function of motile cilia, causing impairment of muco-ciliary clearence, with bacterial overinfection of the upper and lower respiratory tract (chronic oto-sino-pulmonary disease), heterotaxia (situs abnormalities), with/without congenital heart disease, abnormal sperm motility with male infertility, higher frequency of ectopic pregnancy and female subfertility. The presence of recurrent respiratory tract infections in the pediatric age requires differentiation between primary immunodeficiency, diseases with abnormal mucus (e.g., cystic fibrosis) and abnormal ciliary diseases. This case was hospitalized for recurrent respiratory tract infections and total situs inversus at the age of five years, which has enabled the diagnosis of Kartagener syndrome. The PCD confirmation was performed by electron microscopy examination of nasal mucosa cells through which were confirmed dynein arms abnormalities. The diagnosis and early treatment of childhood PCD allows a positive development and a good prognosis, thus improving the quality of life.

Tetralogy of fallot with dextrocardia and situs inversus in a 7-year-old boy

Tetralogy of Fallot is one of the most frequently diagnosed congenital cardiac abnormalities; however, its association with dextrocardia and situs inversus is reported only rarely. We report a case of these findings in a 7-year-old boy, describe the patient's postoperative course, and review the medical literature relevant to these combined conditions.

Symptomatic sick sinus syndrome requiring permanent pacemaker implantation in a patient uwith mirror image dextrocardia with situs inversus and infertility

Situs inversus with dextrocardia is a congenital condition in which the heart is a mirror image of the anatomically normal heart on the right side. A patient presented with the sick sinus syndrome accompanying mirror image dextrocardia which was associated with double superior vena cava and a left sided inferior vena cava A permanent transvenous demand pacemaker was inserted because of repeated episodes of dizziness and a single episode of syncope with ECG showing bradycardia with junctional escape rhythm. Precise knowledge of the venous system and the location of the apex of the right ventricle were necessary prior to permanent pacemaker implantation. Without such knowledge pacing may be technically challenging.