A 47 years old male patient admitted hospital with chest paint. He had anginal complaints before. The electocardiography revaled inferior acute myocardial injury. The patient was hospitalised. With the antiischemic medication his angina revealed. ST segment elevations in the inferior leads returned to the baseline level. The patient had a history of situs inversus with dextrocardia. The past medical history was significant for cigarette smoking, hyperlipidemia and hypertension. On the second day a coronary angiography was performed. On the coronary angiogram the patient was found to have 90% stenosis of the left anterior descending (LAD), 80% of the second obtuse marginal (OM2) branch of the left circumflex coronary artery and 80% stenosis of right coronary artery. There were no associated congenital cardiac abnormalities. Elective coronary artery bypass surgery planned.

Under general anestesia a midline sternotomy was performed (figure 1).

Figure 1

Figure 1: Intra-operative view

LIMA,RIMA and a left radial artery were harvested. Standart aortic and right atrial (left sided) canulation was done. Myocardial protection was obtained with systemic hypotermia 28 C and blood cardioplegia. The radial artery was anastomosed end-to-side to the right corornary artery posterior descending branch and the right internal mammarian artery was anastomosed with an end-to-side fashion to the obtuse 2 branch of the circumflex artery. Llastly, the left internal mammarain artery was anastomosed with an end-to-side fashion to the left anterior descending coronary artery. Under the same cross clamp period proximal anastomose of the radial artery was done to the aorta. The operation was uneventful. Cross clamp period was 35 minutes. Cardiopulmonary bypass time was 45 minutes. The patient was transfered to intensive care unit. Post operative period was uneventfull. Patient was discharged from the hospital on the sixth day.

Discussion

Dextorocardia was the first of the cardiac malpositons decribed by Fabricious in 1606 (₁). Situs inversus totalis with mirror-image dextrocardia was described by Severinus in 1643 (₂). Situs inversus wth dextrocardia ocurs in approximately 1/10.000 patients (₃). Of these patients 15% have Kartagener Syndrome (immotile cilia syndrome) which affects approximately 1/68.000 and is inherited as an autosomal recessive trait (₄). The association of coronary artery disease is of the same frequency as the general population (₅). In patients with situs inversus with dextrocardia normal anatomic cardiac structures and relations are intact but reversed with the anatomic right ventricle anterior to the left ventricle and aortic arch curving to the right and posteriorly. In the literature there were a few cases in which cabg was performed (₆,₇,₈). In all of these cases IMA and saphenous veins were used. This was the only case in which a double mammarian artery used and all arterial revascularisation were performed. Because of the young age arterial grafts were chosen. The length of the both IMA's were enough for in situ bypass. Right coronary artery anastomose was performed from the left side of the operating table becouse of the surgical exposure.

In conclusion CABG with dextrocardia is a challenging case and can be performed with success.

Correspondence to

Yücesin Arslan,MD. Bankacilar sokak. Mine Apt D: 42 81080. Sahrayicedit, Erenköy. Istanbul. Turkey e-mail: yucesinarslan@yahoo.com