CASE REPORT

Closed mitral commissurotomy for mitral stenosiswith dextrocardia—case series

Viju Joseph Abraham & Rajendra Mohan Mathur &

Sanjeev Devgarha & Amita Yadav

Received: 29 March 2014 /Revised: 25 April 2014 /Accepted: 13 May 2014# Indian Association of Cardiovascular-Thoracic Surgeons 2014

Abstract Rheumatic valvular affection is not an uncommondisease especially in the developing nations, but its associa-tion with dextrocardia is relatively rare. In the present dayscenario, where mitral valve replacements far exceed thenumber of closed commissurotomies, a sound understandingof the anatomy, approach, and technique is vital vis-à-vissurgical management of these patients who do not have thefinances for replacement of a severely stenotic valve or pa-tients whomay present in extremis.We present a case series ofthree such patients who underwent successful closedcommissurotomies.

Keywords Closed commissurotomy .Mitral stenosis .

Dextrocardia

Case reports

Case 1

A 23-year-old Indian housewife was admitted in the cardio-thoracic ward with symptoms of indigestion, dull aching painin the right side of her chest, and breathlessness on walking upa flight of 15–20 stairs. On examination, vital signs werenormal. Her apex beat was palpable in the fifth right intercos-tal space. A grade 3/6 mid-diastolic murmur was heard pri-marily at the apex though an opening snap was not appreciat-ed. Chest X-ray showed dextrocardia, straightening of theright heart border, signifying here a left atrial enlargementand a normal cardiothoracic ratio (Fig. 1). Echocardiographic

examination was suggestive of dextrocardia, rheumatic heartdisease, and thickened non-calcific mitral valve, mitral valvearea 0.8 cm

2, valvular gradient of 24 mmHg. Wilkin’s score

was calculated to be 8. There was no thrombus found in theleft atrium or left atrial appendage on transesophagealechocardiography.

She underwent a successful closed mitral valvotomy upto3 cm2 via the right fifth intercostal space with no postoperativeclinical or echocardiographic evidence of mitral regurgitation.

Case 2

A 26-year-old manual laborer presented in the emergencydepartment with complaints of acute onset breathlessness,giddiness, and swelling of his feet. On examination, he wasof regular build and averagely nourished. Peripheries werecold and clammy, pedal edema was noted, blood pressurerecorded as 80/50 mmHg, pulse rate was 100/min. Systemicexamination revealed bilateral coarse crepitations in the chest,heart sounds in the right side of the chest with the presence ofa distinct opening snap. A grade 4/6 mid-diastolic murmurwas appreciated in the right parasternal region. Chest X-rayshowed dextrocardia with pulmonary edema. Echocardiogra-phy revealed severe non-calcific mitral stenosis with a valvearea of 0.6 cm2, LA size of 60 mm, and a valvular gradient of30 mmHg.

He was stabilized with inotropic supports, diuretics andwas subsequently taken up for closed mitral valvotomy viathe right fifth intercostal space. Inotropic supports were grad-ually tapered, and he was discharged on the sixth postopera-tive day.

Case 3

A 16-year-old high school student was admitted with com-plaints of progressively increasing dyspnea over the past

V. J. Abraham (*) : R. M. Mathur : S. Devgarha :A. YadavDepartment of Cardiothoracic and Vascular Surgery, Sawai ManSingh Hospital, Jaipur, Rajasthan, Indiae-mail: abrahamviju@yahoo.co.in

Indian J Thorac Cardiovasc SurgDOI 10.1007/s12055-014-0283-z

6 months, which had progressed to NYHA class III. She gavea history of frequent episodes of fever with joint pains duringchildhood which were treated symptomatically. On examina-tion, vital signs were stable. On cardiovascular examination,the apex beat was palpated in the right fifth intercostal space,first heart sound was loud and there was a grade 3/6 middiastolic murmur in the right parasternal area. Chest X-rayshowed dextrocardia, straightening of the right heart border.Echocardiography was suggestive of rheumatic valvular heartdisease, valvular area 0.8 cm2, gradient of 28 mmHg. Therewas no calcification and no thrombus seen in the left atrium oratrial appendage.

She was taken up for closed mitral commisurotomy via theright fifth intercostal space. Postoperative course was unevent-ful, and she was discharged on the fourth postoperative day.

Discussion

Marco Severino is the first to have recognized dextrocardia in1643. It was more than a hundred years later that MatthewBaillie described the complete mirror image reversal of thethoracic and abdominal organs in situs inversus—said to bepresent in 0.01 % of the population. The first case ofdextrocardia with acquired valvular heart disease was reportedby Owen in 1911. The first successful surgical correction ofmitral stenosis with dextrocardia was reported in 1953, fol-lowing which there have been very few reports [1].

The prevalence of mirror image dextrocardia has beenestimated to be 1 in 10,000. This is a congenital disorder inwhich the heart is situated in the right hemithorax. The leftatrium and ventricle lie posteriorly forming the right cardiacborder and the vena cavae are on the left side. The pulmonaryartery is anterior to and to the right of the aorta. Associateddefects with dextrocardia include among others, atrial andventricular septal defects, patent ductus arteriosus, truncus

arteriosus, and total anomalous pulmonary venous return [2,3].

The association of situs inversus with dextrocardia is notuncommon. Patients with these features are found to have anumber of skeletal abnormalities as well such ashemivertebrae, spina bifida occulta, six lumbar vertebrae,Klippel–Feil syndrome and cervical ribs [4].

A combination of clinical examination, chest X-ray find-ings, electrocardiography, and echocardiography confirms thediagnosis of dextrocardia. Echocardiogram and cardiac cath-eterization are useful modalities to diagnose associated defectsas well [5].

Surgical approach to closed mitral commissurotomy is infact a mirror image of the conventional approach as to apatient with levocardia. Thoracotomy is performed through aright anterolateral fifth interspace incision. The pericardium isopened anterior to the right phrenic nerve. The left atrialappendage is identified forming the right cardiac border, andthe left anterior descending artery defines the position of theventricular septum. The left ventricular apex is identifiedlateral to the left anterior descending artery. A purse string

Fig 1 Preoperative andpostoperative chest X-rays in apatient with dextrocardia whounderwent closed mitralcommissurotomy

Fig 2 Diagrammatic representation of the operative technique for closedmitral valvotomy in a patient with dextrocardia

Indian J Thorac Cardiovasc Surg

suture and snare is placed at the LV apex. A stab wound ismade at the center of the LV apical suture, which is thendilated, snared, and secured. A similar purse string suturemay be applied to the LA appendage or stay sutures appliedto the edges of the incision which is just adequate enough toadmit the left index finger. An important aspect is the need toswitch hands for the operating surgeon, while the left indexfinger would explore the mitral valve, the right hand wouldguide the dilator through the ventricular apex for subsequentvalvotomy [5, 6] (Fig. 2). Successive dilatations may berequired, first with the opening of the dilator set at 2.5 cmandmaximum settings of the dilator in small patients not morethan 3.3 to 3.5 cm. The Tubb’s dilator is removed and thesnare reapplied making sure that it does not get too tight, lest itcuts through the ventricular muscle. Once the heart has recov-ered, the index finger is slowly removed while simultaneouslyapplying a side biting clamp to the lips of the incision on theappendage. This incision is closed with interrupted stitches.Residual bleeding can be controlled with full-thicknessinterrupted stitches at the stab wound. Potential complicationsof this procedure include bleeding, arrhythmia, and injury tothe phrenic nerve.

Tavassoli et al. reported a case of a 25-year-old man withsitus inversus and dextrocardia subjected to percutaneoustransvenous mitral commissurotomy. Though the procedurewas successful, the authors have prudently mentioned theinherent risks of the procedure, especially the technical chal-lenges of transseptal catheterization in a malpositioned heartand possibilities of cardiac perforation [7, 8].

With the development of superior grade mechanical andbioprosthetic valves, the surgical indications as well as thepractice of closed mitral commisurotomy have been dwin-dling worldwide. In a country such as India, where a vast

number of people do not have the means or the resources toopt for a valve replacement, closed mitral valvotomy is aviable option. A sound understanding of the anatomy wouldhelp the surgeon tackle incidental anomalies such asdextrocardia effectively.

Conflict of Interest The authors have declared that no conflict ofinterest exists

References

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2. Berkowitz D, Likoff W. Mitral stenosis complicating situs inversus. Acase successfully treated by commissurotomy. Ann Intern Med.1954;40:784–8.

3. Bopp P, Bwat P, Lemonnier J. Rheumatic heart disease anddextrocardia. Arch Intern Med. 1964;113:19–22.

4. Davies ETL, Duffy JP, Kamdar HH.Mitral valvotomy in situs inversuswith associated skeletal anomalies. Br Heart J. 1965;27:148–50.

5. Lansing AM, Scofield ELW. Mitral valvotomy in a patient withdextrocardia and situs inversus. Chest. 1974;66:580–2.

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