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Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 218-220
How standard transesophageal echocardiography views change with dextrocardia


Department of Cardiac Anaesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India

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Date of Submission10-Oct-2012
Date of Acceptance06-Mar-2013
Date of Web Publication29-Jun-2013
 

   Abstract 

Dextrocardia with situs inversus is a rare condition. Situs inversus with dextrocardia is also called as "situs inversus totalis". Transesophageal echocardiography (TEE) views in dextrocardia patient are not discussed in the literature. The cardiac position and the cardiac chambers are mirror image of the normal anatomy. Because of this positional change, certain TEE probe and multiplane angle manipulations are required to obtain the recommended views.

Keywords: Dextrocardia, Situs inversus, Transesophageal echocardiography

How to cite this article:
Raut MS, Maheshwari A, Shad S, Rachna G. How standard transesophageal echocardiography views change with dextrocardia. Ann Card Anaesth 2013;16:218-20

How to cite this URL:
Raut MS, Maheshwari A, Shad S, Rachna G. How standard transesophageal echocardiography views change with dextrocardia. Ann Card Anaesth [serial online] 2013 [cited 2019 Dec 14];16:218-20. Available from: http://www.annals.in/text.asp?2013/16/3/218/114261


A 60-years-old male patient presented with a history of chest pain on exertion. On investigation, he was found to have type I dextrocardia (mirror-image dextrocardia) with situs inversus not associated with any other congenital abnormality. Electrocardiogram (ECG) with right sided precordial leads (normal chest leads positions reversed) and right arm-left arm electrodes placed in the usual position [Figure 1] showed typical pattern of dextrocardia - right-axis deviation of the P wave (negative in aVL and lead I and positive in aVR; and aVR similar to aVL of a normal ECG). The chest X-ray [Figure 2] showed dextrocardia, right-sided aortic arch, cardiac apex and gastric air bubble. Coronary angiography revealed triple vessel disease and the patient was scheduled for off pump coronary artery bypass grafting. Due to dextrocardia, right internal mammary artery was anastomosed to the anterior ventricular artery (left anterior descending artery), and venous grafts were anastomosed to posterior descending artery and ramus intermedius. Intraoperative transesophageal echocardiography (TEE) was performed. In contrast to multiplane angles used to obtain recommended TEE views in situs solitus patient, different angle range was required to obtain the desired views.
Figure 1: Electrocardiogram in dextrocardia - P wave is negative in aVL and lead I, and positive in aVR

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Figure 2: Postoperative chest X-ray in dextrocardia with central venous line inserted through right internal jugular vein (IJV), gastric bubble seen on the right side

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Midesophageal four chamber view was obtained at 0° angle with the right atrium and right ventricle on the right side of display which is opposite of TEE finding in situs solitus [Figure 3]; [Video 1]. Long axis of coronary sinus view was seen by slightly advancing and retroflexing the probe from the midesophageal four-chamber view, and coronary sinus was seen on the left side of display at 0° [Figure 4]. Normally, long axis of coronary sinus is seen on the right side of display. Midesophageal aortic valve (AV) long axis view was developed by keeping the AV in the center of the display while rotating the transducer forward to a multiplane angle of 10°-20° until the left ventricular outflow tract (LVOT), AV, and proximal ascending aorta lined up in the image [Figure 5]; [Video 2]. Normally, the midesophageal AV long axis view is seen at a multiplane angle of 120°-160°. Aortic valve short axis view was imaged by manipulating depth of the probe until the AV come into view, and then the multiplane angle was rotated forward to 110° [Figure 6]; [Video 3]. Normally, this view is obtained at a multiplane angle of 30°-60°. Bicaval view was seen at 70° [Figure 7]; [Video 4]. Normally, midesophageal bicaval view is developed by rotating the transducer forward to between 80° and 110°. Transgastric basal short axis view is obtained in a similar way as it is obtained in a normal heart; the only difference is right ventricle is seen on the right side of display in contrast to TEE image of a normal heart where it is seen on the left side [Figure 8]; [Video 5]. The deep transgastric long axis view was obtained by anteflexing and gently advancing probe from midtrangastric short axis view while manipulating the multiplane transducer angle to 30°-50° [Figure 9]; [Video 6]. Aortic valve was seen on the right side of the display. Normally, deep transgastric view is obtained at an angle of 0° with aortic valve seen on the left side of the displayed TEE image.
Figure 3: Transesophageal echocardiogram mid esophageal 4 chamber view in mirror image dextrocardia

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Figure 4: Transesophageal echocardiogram coronary sinus view in mirror image dextrocardia

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Figure 5: Transesophageal echocardiogram mid esophageal long axis view in mirror image dextrocardia

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Figure 6: Transesophageal echocardiogram mid esophageal AV short axis view in mirror image dextrocardia

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Figure 7: Transesophageal echocardiogram bicaval view in mirror image dextrocardia

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Figure 8: Transesophageal echocardiogram transgastric basal short axis view in mirror image dextrocardia

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Figure 9: Transesophageal echocardiogram deep transgastric view in mirror image dextrocardia

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Dextrocardia is an abnormal congenital positioning of the heart. In contrast to the formation of the heart in the fetus on the left side, it flips over and forms on the right side. [1] [Figure 10] Situs inversus is a congenital condition in which the main visceral organs are reversed or mirrored from their normal positions. Dextrocardia with a normal abdominal situs is associated with congenital cardiac anomalies like transposition of the great vessels and atrial [2] and ventricular septal defects [3] in 90-95% of cases. However, dextrocardia with situs inversus is associated with a lower incidence of congenital heart disease (0-10%). Dextrocardia with situs inversus is rare occurring in about 1 in 10000. [4] Situs inversus with dextrocardia is also called as "situs inversus totalis". Because of this positional change and abnormal looping, certain TEE probe and transducer manipulations are required to acquire the recommended views.
Figure 10: Schematic diagram showing mirror image dextrocardia

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   References Top

1.Abdur-Rahman LO, Adeniran JO, Taiwo JO. Concurrent dextrogastria reverse midgut rotation and intestinal atresia in a neonate. J Indian Assoc Paediatr Surg 2007;12:228-30.  Back to cited text no. 1
    
2.Iino K, Watanabe G, Ishikawa N, Tomita S. Total endoscopic robotic atrial septal defect repair in patient with dextrocardia and situs inversus totalis. Interact Cardiovasc Thorac Surg 2011;1:1-2.  Back to cited text no. 2
    
3.Piryani RM, Shukla A, Prasad DN, Kohli SC, Shrestha G, Singh D. Situs inversus with dextrocardia with multiple cardiac lesions in adult. Kathmandu Univ Med J (KUMJ) 2007;5:247-9.  Back to cited text no. 3
[PUBMED]    
4.Nawaz A, Matta H, Hamchou M, Jacobez A, Trad O, Al Salem AH. Situs inversus abdominus in association with congenital duodenal obstruction: A report of two cases and review of the literature. Pediatr Surg Int 2005;21:589-92.  Back to cited text no. 4
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Correspondence Address:
Monish S Raut
Department of Cardiac Anaesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.114261

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

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