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Asian Cardiovasc Thorac Ann 2002;10:53-54
© 2002 Asia Publishing EXchange Pte Ltd

CASE STUDY

Situs Inversus and Coronary Artery Disease

Nevzat Erdil, MD, Levent Çetin, MD, Erol Sener, MD, Ufuk Demirkiliç, MD, Cemal Sag, MD1

Department of Cardiovascular Surgery
1 Department of Cardiology Alkan Hospital Ankara, Turkey
Nevzat Erdil, MD Tel: 90 422 341 0660 Fax: 90 422 341 0728 email: n_erdil{at}yahoo.com Department of Cardiovascular Surgery, Turgut Özal Medical Center, Inönü University Faculty of Medicine, Elazig Yolu Street, Malatya 44069, Turkey.

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
Situs inversus is a rare condition and there are few reports of myocardial revascularization in such patients. A 56-year-old woman with situs inversus totalis and coronary artery disease underwent successful anastomosis of the right internal mammary artery to the anterior descending coronary artery, and a saphenous vein graft to the right coronary artery.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Dextrocardia associated with situs inversus is a rare condition; its incidence is 1:10,000.1 Usually, only people with dextrocardia combined with situs inversus totalis survive long enough to develop ischemic atherosclerotic heart disease.2 The incidence of coronary artery disease in those with situs inversus totalis and dextrocardia is similar to that of the general population. Thus, there are few cases of atherosclerotic coronary artery disease with situs inversus totalis throughout the world. This report describes the first coronary bypass operation in Turkey on a patient with situs inversus totalis.


   CASE REPORT
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 56-year-old woman with situs inversus totalis presented with stable angina pectoris and a history of non-insulindependent diabetes mellitus, bronchial asthma, and a previous anteroseptal myocardial infarction. There was no history of smoking or familial coronary disease. Physical examination and chest and abdominal radio-graphy were normal except for the typical signs of situs inversus (Figure 1Go). Cardiac angiography demonstrated severe 2-vessel disease with high-grade lesions in the proximal left anterior descending and right coronary arteries. Ventriculography indicated hypokinesia in two segments of the left ventricle. The patient underwent coronary artery bypass grafting under cardiopulmonary bypass using a nonpulsatile bypass circuit and a membrane oxygenator (Dideco d-708; Simplex, Mirandola, Italy). Moderate systemic and topical hypothermia, cold crystalloid cardioplegia, and warm reperfusion were applied for myocardial protection. After a midline sternotomy, the right internal mammary artery (IMA) and the saphenous vein were harvested. The right IMA was anastomosed to the left anterior descending artery, and saphenous vein was used to bypass the right coronary artery. There was no complication in the postoperative period. Intensive care unit stay was 16 hours and the patient was discharged on the 6th postoperative day with antiplatelet therapy. She was free from angina at the early follow-up examination. At 6 months postoperatively, coronary angiography showed patency with good distal runoff in both grafts (Figure 2Go).



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  		Figure 1. Preoperative posteroanterior chest radiograph.

 


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  		Figure 2. Angiogram in the left anterior oblique projection, showing the right internal mammary artery graft to the anterior descending artery.

 

   DISCUSSION
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 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
There have been a few reported cases of myocardial revascularization by anastomosis of the right IMA to the anterior descending coronary artery in patients with dextrocardia and situs inversus.1,3 Other patients with this condition have received saphenous vein grafts.4,5 Surgical treatment of multivessel disease in such cases is extremely uncommon.

Use of the left IMA to bypass the anterior descending coronary artery has become the standard procedure, based on reports of superior graft patency, reduced cardiac events, and enhanced survival compared with patients receiving vein grafts alone. Because of the altered coronary anatomy in dextrocardia with situs inversus totalis, the right IMA is recommended as the first choice of graft for the anterior descending artery. It was found that use of the right IMA was very convenient in this unusual anatomic situation.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Abernus H, Ramires JA, Dallan LA, Jatene A. Right mammary-coronary anastomosis in a patient with situs inversus. Chest 1988;94:886–7.[Abstract/Free Full Text]

  2. Hynes KM, Gau GT, Titus JL. Coronary heart disease in situs inversus totalis. Am J Cardiol 1973;31:666–9.[Medline]

  3. Mesa JM, Aroca A, Frutos A, Centeno J, Silvestre J, Baset F. Situs inversus and myocardial revascularization. J Cardiovasc Surg 1995;36:571–2.[Medline]

  4. Irvin RG, Ballenper JF. Coronary artery bypass surgery in a patient with situs inversus. Chest 1982;81:380–1.[Free Full Text]

  5. Moreno Cabral RJ, Daily PO. Coronary bypass in dextrocardia. Chest 1984;5:714.




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Should you stand on the left or the right of a patient with dextrocardia who needs coronary surgery?
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[Abstract] [Full Text] [PDF]

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Ufuk Demirkiliç
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