We report our experience of two patients suffering from severe coronary artery disease and situs inversus totalis with dextrocardia. The surgeon, standing on the right side of the patients, performed coronary artery bypass grafting by harvesting the right internal mammary artery in lieu of the left one

Abbas SalehiOmran

Abbasali Karimi

Hossein Ahmadi

IF Tabry

KM Hynes

P Bonde

Parin Yazdanifard

Journal of Medical Case Reports

English

PubMed

Springer - Publisher Connector

BioMed CentralJournal of Medical Case Reports
ssOpen AcceCase report
Total myocardial revascularization for situs inversus totalis with 
dextrocardia: a case report
Abbasali Karimi*1, Abbas SalehiOmran1, Hossein Ahmadi1 and 
Parin Yazdanifard2
Address: 1Department of Cardiothoracic Surgery, Tehran Heart Centre, Medical Sciences/University of Tehran, Tehran, Iran and 2Department of 
Clinical Research, Tehran Heart Centre, Medical Sciences/University of Tehran, Tehran, Iran
Email: Abbasali Karimi* - abbasalikarimi2006@yahoo.com; Abbas SalehiOmran - abbasomran2006@yahoo.com; 
Hossein Ahmadi - dr.ahmadi2006@yahoo.com; Parin Yazdanifard - parinyazdanifard@yahoo.com
* Corresponding author    
Abstract
We report our experience of two patients suffering from severe coronary artery disease and situs
inversus totalis with dextrocardia. The surgeon, standing on the right side of the patients,
performed coronary artery bypass grafting by harvesting the right internal mammary artery in lieu
of the left one.
Introduction
Dextrocardia, defined as the presence of a right-sided heart,
can be mirror image or isolated. Situs inversus totalis with
dextrocardia was first described by anatomist surgeon Marco
Aurelio in 1643 [1]. The etiology of this anomaly, with an
approximate prevalence of 1–2/10,000 normal population,
has hitherto eluded the medical community, although it is
thought to be autosomal recessive. The rate of atherosclerotic
heart disease in people with this condition is similar to the
general population [2]. We present our experience with 2
cases of situs inversus totalis with dextrocardia. The patients,
who had coronary artery disease, underwent coronary artery
bypass grafting (CABG) with the surgeon standing on the
right side of the patients and the right internal mammary
artery (RIMA) harvested for bypass grafting instead of the left
internal mammary artery (LIMA).
Case A
A 58-year-old woman, who had experienced myocardial inf-
arction (MI) one year previously, presented with post MI
angina. Already diagnosed with situs inversus totalis with
dextrocardia, she had a history of diabetes, hypertension,
hyperthyroiditis and hypercholesterolemia. Coronary angi-
ography showed three-vessel disease with significant stenosis
in the proximal and mid portions of the left anterior
descending (LAD) artery, distal portion of the left circumflex
(LCX) artery and proximal and mid portions of the right cor-
onary artery (RCA). Left ventricular ejection fraction (LVEF)
was about 60%. Elective CABG was considered for the
patient. A median sternotomy revealed that the heart occu-
pied exactly the mirror image of its normal position. The
saphenous vein and RIMA were harvested by the surgeon,
standing on the right side of the patient instead of the left
side. Cannulation was performed, and a routine antegrade
cardioplegia was administered.
The RIMA and saphenous vein grafts were grafted on the
LAD, obtuse marginatus (OM) and RCA, respectively. Cardi-
opulmonary bypass (CPB) time and aortic cross-clamp time
were 51 and 80 minutes, respectively. The patient was
weaned from CPB in normal sinus rhythm and without ino-
tropic support. The postoperative course being smooth and
Published: 5 May 2007
Journal of Medical Case Reports 2007, 1:18 doi:10.1186/1752-1947-1-18
Received: 2 January 2007
Accepted: 5 May 2007
This article is available from: http://www.jmedicalcasereports.com/content/1/1/18
© 2007 Karimi et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2
(page number not for citation purposes)
Journal of Medical Case Reports 2007, 1:18 http://www.jmedicalcasereports.com/content/1/1/18uneventful, the patient was discharged on the 8th postopera-
tive day in good condition. Figure 1 shows the angiographic
features of significant stenosis in the mid portion of the right
coronary artery (RCA) of the patient.
Case B
A 46-year-old man, already diagnosed with situs inversus
totalis with dextrocardia and coronary artery disease, pre-
sented with signs and symptoms of chronic stable angina.
He was a cigarette smoker, and had suffered myocardial inf-
arction about two years before. After coronary angiography,
showing three-vessel disease with significant stenosis in the
proximal part of the LAD, circumflex and right coronary
arteries and an approximate ejection fraction of 50–60%, the
patient underwent elective CABG. A median sternotomy was
performed, revealing the heart occupying exactly the mirror
image of its normal position. Similar to the previous case, the
surgeon stood on the right side of the patient to harvest the
saphenous vein and RIMA. Cannulation was carried out, and
an antegrade cardioplegia was administered routinely. The
RIMA and three vein grafts were grafted on the LAD, OM,
diagonal and distal portion of RCA, respectively. CPB and
aorta cross-clamp times were 93 and 57 minutes, respec-
tively. The patient was weaned from CPB without inotropic
support in normal sinus rhythm. The patient had an une-
ventful postoperative course and was discharged 6 days after
surgery.
Discussion
Not only is dextrocardia with situs inversus totalis a rare find-
ing, there are also only a few reports of this anomaly in tan-
dem with coronary artery disease and CABG in the existing
literature [2-4]. The rate of coronary artery disease in those
with this anomaly is similar to that in the normal population
[2].
There are two significant points in our method that merit
due attention. First, in contrast to previous studies reporting
the surgeon standing on the left side of the patient [3], our
surgeon performed uneventful operations while standing on
the right side of the patient. Second, the RIMA, rather than
LIMA, was harvested for grafting on the left anterior descend-
ing artery.
In conclusion, mirror-image anatomy does not pose an unu-
sual technical challenge in total myocardial revascularization
and surgeons can perform surgery without difficulty while
standing on the right side of the patient.
Abbreviations
Coronary artery bypass grafting (CABG), Right internal
mammary artery (RIMA), Left internal mammary artery
(LIMA), Myocardial infarction (MI), Left anterior descending
(LAD), Right coronary artery (RCA), Left ventricular ejection
fraction (LVEF), Left circumflex(LCX), Obtuse marginatus
(OM), Cardiopulmonary bypass (CPB).
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
AK carried out the surgery and was directly involved in the
conception, design and drafting of the manuscript. AS and
HA participated in the surgery; they also gave critical com-
ments on the results and participated in planning and coor-
dinating the study. PY collaborated in the design of the study
and was directly involved in drafting and revising the manu-
script. All the authors read and approved the final manu-
script.
Acknowledgements
Written consent was obtained from the patients for the publication of this 
study.
References
1. Cleveland M: Situs in versus viscerum: anatomic study.  Arch surg
1926, 13(343):.
2. Hynes KM, Gau GT, Titus JL: Coronary heart disease in situs in ver-
sus totalis.  Am J cardiology 1973, 31(5):666-9.
3. Bonde P, Campalani GF: Myocardial revascularization for situs
inversus totalis and dextrocardia.  Interact CardioVasc Thorac Surg
2003, 2:486-488.
4. Tabry IF, Calabrese J, Zammar H, Abou-Kasem K, Akeilan H, Gharbieh
N, et al.: Case report: off-pump total myocardial revasculariza-
tion for dextrocardia and situs inversus.  Heart Surg Forum 2001,
4(3):251-253.
Chest X-Ray of patient No-1Figure 1
Chest X-Ray of patient No-1.Page 2 of 2
(page number not for citation purposes)


Total myocardial revascularization for situs inversus totalis with dextrocardia: a case report

Crossref

Campalani GF: Myocardial revascularization for situs inversus totalis and dextrocardia. Interact CardioVasc Thorac Surg

Case report: off-pump total myocardial revascularization for dextrocardia and situs inversus. Heart Surg Forum

JL: Coronary heart disease in situs in versus totalis.

Situs in versus viscerum: anatomic study. Arch surg

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Total myocardial revascularization for situs inversus totalis with dextrocardia: a case report

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