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| CASE REPORT |
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| Year : 2021 | Volume
: 12
| Issue : 3 | Page : 165-167 |
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Dextrocardia: Clinical vignettes
Ramesh Aggarwal1, Shridhar Dwivedi2
1 Department of Medicine, Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi, India
2 Head, Academics, National Heart Institute, East of Kailash, New Delhi, India
| Date of Submission | 02-Apr-2021 |
| Date of Acceptance | 02-Apr-2021 |
| Date of Web Publication | 09-Jul-2021 |
Correspondence Address:
Prof. Ramesh Aggarwal
Department of Medicine, Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi - 110 001
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_40_21
Dextrocardia is one of the rare cardiac positional anomalies, in which heart is located in the right side of thorax with its base-to-apex axis positioned to the right side. Dextroposition is different than dextrocardia where the heart is displaced to the right secondary to extracardiac causes like eventeration of diaphragm and right lung hypoplasia. The term situs solitus is used when heart and abdominal viscera are normally placed with the cardiac apex, spleen, stomach, and aorta are placed on the left side and inferior vena cava and liver placed on the right side, whereas situs inversus has mirror-image of the organs relative to their position in situs solitus. Dextrocardia, cardiac dextroposition, and situs inversus generally remain asymptomatic and are detected incidentally by imaging studies done for reasons other than cardiovascular system related problems. This article shares our experience of five cases of cardiac malposition that presented with atypical features of common medical problems. It highlights the importance of basic clinical examination in these patients which helps in making a bed side diagnosis of cardiac malposition and also prevents any mishap which can arise if any emergency intervention is done in patients of dextrocardia with or without situs inversus.
Keywords: Cardiac malposition, dextrocardia, situs inversus
How to cite this article:
Aggarwal R, Dwivedi S. Dextrocardia: Clinical vignettes. Indian J Med Spec 2021;12:165-7 |
| Introduction | |  |
Dextrocardia is one of the rare cardiac positional anomalies with an incidence rate around 1 in 12000 pregnancies.[1] In this, heart is located in the right side of thorax with its base-to-apex axis positioned to the right side. This condition is not caused by any extracardiac abnormality and it should always be differentiated from cardiac dextroposition where the heart is displaced to the right secondary to extracardiac causes such as eventeration of diaphragm, right lung hypoplasia, or right lung pneumonectomy.[2],[3],[4]
Situs is a term which determines the position of the heart and viscera relative to midline. Situs solitus is used when heart and abdominal viscera are normally placed with the cardiac apex, spleen, stomach, and aorta are placed on the left side and inferior vena cava and liver placed on the right side. Only <1% of such individuals have any other congenital heart disease. Situs inversus has mirror-image of the organs relative to their position in situs solitus. Two broad subcategories have been described. First is “Situs inversus with dextrocardia,” which is commoner and has mirror image position of the heart and viscera relative to situs solitus, with the cardiac apex, spleen, stomach, and aorta located on the right side and the liver and IVC located on the left side. Congenital heart disease occurs in only 3%–5% of such individuals. The other category “Situs inversus with levocardia” is a very rare abnormality characterized by mirror-image position of the visceral organs relative to situs solitus with a left-sided cardiac apex. Situs ambiguous also known as heterotaxia is characterized by abnormal arrangement of vessels and organs relative to situs solitus. The two major subcategories are situs ambiguous with polysplenia and situs ambiguous with asplenia. Both of them are associated with other congenital heart diseases in >50% of cases.
| Case Report | | |
Dextrocardia, cardiac dextroposition, and situs inversus generally remain asymptomatic and are detected incidentally by imaging studies done for reasons other than cardiovascular system related problems. Over the last 20 years, we came across five cases of cardiac malposition which presented with common medical problems but in an atypical presentation way.[5] The detailed description of all the five cases is tabulated in [Table 1].
| Discussion | | |
The presence of cardiac malposition and situs inversus in a patient can lead to misinterpretation of common presentation of diseases. Example: the pain of myocardial infarction is felt on right side, pain of cholecystitis in left hypochondrium, pain of appendicitis in left iliac region. In the above-mentioned case 1 and case 2, there was atypical site of chest pain, right side chest, right arm, and epigastrium, respectively. In the absence of electrocardiogram (ECG) or X-ray chest, it was difficult to suspect angina at first instance. However, the location of cardiac apex to the right side along with characteristic ECG changes on lead reversal and right sided leads, the diagnosis was confirmed.
It should be remembered that cardiopulmonary resuscitation in any patient of dextrocardia should be attempted on the right side instead of usual left side. Placement of defibrillator, ECG leads and probes for transthoracic echocardiography should be done carefully as per anatomical localized heart to avoid errors.
Malposition of heart and viscera also pose a challenge to the intervention cardiologists and gastro surgeons. Angiography and cardiac bypass procedures in the presence of mirror image of heart and great vessels needs expertise and training by the doctors.
Similarly, any abdominal procedure like liver biopsy or any emergency surgery done in an undetected situs inversus patient can be life threatening. Careful abdominal examination would elicit hepatic dullness on left side and can prevent such mishaps. Case 5 had pain of appendicitis in the left iliac fossa. Sonography supplemented with clinical examination could make the diagnosis of appendicitis confirmed in this case. It should be remembered that in 50% of the cases a left-sided appendix may present with pain on the right side. It is due to the fact that despite transposition of viscera, the nervous component of the system is not reversed. Furthermore, precautions are needed while doing colonoscopy and the identification of colon and the splenic flexures in the presence of transposition of viscera. Similarly, difficulties may be encountered in special procedures such as endoscopic retrograde cholangiopancreatography, catheter angiography, and percutaneous transhepatic cholangiography.
Awareness of the presence of anomaly by the patient himself and educating the patient is also of paramount importance. This can help in preventing any catastrophic event especially when the doctor is unsuspecting any cardiac or visceral transposition. Case 4 came with acute gouty arthritis and as he already knew about his problem of cardiac disposition, he informed us. This saved both the time and unnecessary work up and expenditure in investigating him.
| Conclusion | | |
An astute physician should be aware of the atypical presentations of common medical and surgical disorders in patients of dextrocardia and situs inversus. If a systematic clinical examination is done and it is supplemented with X-ray chest, ECG and ultrasound, dextrocardia would not be missed usually and clinical correlation even in atypical presentation can be made easily. Further patient education and awareness about the presence of any visceral transposition can prevent major mishap in future even if it remains unsuspected by the doctor.
Statement of ethics
As a matter of policy, we take consent of every patient before we publish. Written consent of all the patients have been taken in this paper.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bohun CM, Potts JE, Casey BM, Sandor GG. A population-based study of cardiac malformations and outcomes associated with dextrocardia. Am J Cardiol 2007;100:305-9.  |
| 2. | Maldjian PD, Saric M. Approach to dextrocardia in adults: Review. AJR Am J Roentgenol 2007;188:S39-49. |
| 3. | Bharati S, Lev M. Positional variations of the heart and its component chambers. Circulation 1979;59:886-7. |
| 4. | Fulcher AS, Turner MA. Abdominal manifestations of situs anomalies in adults. Radiographics 2002;22:1439-56. |
| 5. | Agarwal MP, Dwivedi S, Gupta A. Acute myocardial infarction in situs inversus totalis. Indian J Cardiol 2000;3:67-8. |
[Table 1]
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