Congenital dextrocardia complicated by hypertension,coronary artery disease and myocardial infarction

The case record of a seventy-three year old man with congenital dextrocardia and situs inversus viscerum complicated by hypertension, coronary artery disease and myocardial infarction is presented. Electrocardiographic recordings of the limb leads, with and without reversal of the arm lead wires, and of the precordial leads of the V series derived from both right and left chest areas are presented. In this instance the electrocardiographic findings in precordial leads taken over the right chest point to fresh anteroseptal infarction; those leads recorded from the left chest were not informative. This serves to emphasize the fact that precordial leads should be recorded from the right side of the chest rather than the left in order that the exploring precordial electrode may overlie the area of cardiac damage, and thus manifest maximal changes in the electrocardiogram. We agree that the electrocardiogram may best be interpreted by application of the usual criteria to the limb leads taken with the arm lead wires reversed although in this case the limb leads yielded no information of diagnostic significance.     

Relationship between location of chest pain and site of coronary artery occlusion

Chest pain characteristics and site of coronary artery occlusion were evaluated in 148 patients having single-vessel coronary angioplasty and in 95 patients having double-vessel angioplasty. The locations of chest pain included substernal and left precordium, right precordium and epigastric. The possible sites of pain radiation were limited to neck/jaw, left arm, right arm, and interscapular. The patient described whether or not the pain was typical of previous angina, and the presence of ST segment deviation was noted to be certain that ischemia was present. The analysis showed that the occluded artery could not be reliably identified. However, it was possible to say which artery was most likely not diseased. Patients presenting with substernal or left chest pain with radiation to the left arm had a less than 10% chance of having right coronary artery disease. A patient presenting with epigastric pain radiating to the neck or jaw had a less than 13% chance of having left anterior descending disease. It is concluded that in patients with single- and double-vessel coronary disease, there is some relationship between chest pain pattern and disease location.     

Acute anteroseptal myocardial infarction in a patient with dextrocardia

Dextrocardia with situs inversus is an uncommon congenital condition in which the major visceral organs are reversed. The clinical diagnosis and electrocardiographic localization of myocardial infarctions in these patients remain a great challenge. We report a case of a 64-year-old man known with dextrocardia and situs inversus totalis presenting with acute chest pain irradiating to the right arm. The admission and reversed “normalized” electrocardiogram are presented, allowing for correct diagnosis of an acute anteroseptal myocardial infarction. The present case emphasizes the importance of performing a reversed electrocardiogram in patients with dextrocardia.     

Electrical cardioversion of atrial fibrillation in a case of dextrocardia

Although atrial fibrillation is one of the most frequent and widespread cardiac arrhythmias, there is not sufficient data on frequency and electrical cardioversion of this arrhythmia in cases of dextrocardia. The present case report describes a 66-year-old woman with atrial fibrillation and dextrocardia who was admitted to hospital with a complaint of palpitations; no cause of the atrial fibrillation was found. Electrical cardioversion was performed for termination of the arrhythmia. By placing the anterior paddle in the right parasternal area and the lateral paddle in the area where the apex of the left ventricle palpated at the right side of the chest, cardioversion was performed and sinus rhythm was achieved.     

Bilateral coronary artery fistulas communicating with main pulmonary artery and left ventricle: case report

Coronary artery fistula is an uncommon congenital malformation that generally drains into the main pulmonary artery or the right side of the heart. This is a case report on bilateral coronary artery fistulas communicating with the main pulmonary artery and the left ventricle. A 65-year-old woman was investigated for recurrent chest pain. Coronary angiography revealed this anomalous coronary artery connection without evidence of atherosclerotic coronary artery disease. The rarity of coronary artery fistulas involving both the main pulmonary artery and the left ventricle is emphasized.     

Evaluation of the ECG recording in abnormal positions of the heart in the thorax

Abnormal localization of the heart in the chest is a rare congenital developmental disorder (1,10). Even if the heart is in these instances normally developed, its abnormal position leads in case of its affection by disease to diagnostic and therapeutic difficulties, in particular when an invasive procedure must be used. With regard to the entirely different position of individual cardiac departments it is necessary to differentiate carefully between dextrocardia and dextroversion (15). Dextroposition is only a marginal problem. A very satisfactory diagnostic method in these anomalies is the ECG tracing, where we encounter quite typical pictures. Dextrocardia and dextroversion are characterized by a similar mirror image reversed tracing in the leads from the extremities. It differs, however, fundamentally in the chest lead tracings. In dextrocardia during tracing of standard thoracic leads we follow the predominant negative QRS complex in all leads; when including the dextrolateral thoracic leads the curve "becomes normal". In dextroversion, with regard to the anterior position of the left ventricle the dominating finding is a high R wave in all leads from the left and right side of the chest.     

真性镜像右位心急性心肌梗死患者介入治疗1例及其诊疗思路

镜像右位心是心脏生理性变异情况下,心脏位于正常人心脏右侧镜面位的情况,而其中伴全身其他脏器转位的称为真性右位心.临床中真性右位心患者合并急性心肌梗死实属罕见.本文通过报道1例真性镜像右位心急性心肌梗死患者行介入治疗成功的案例,对真性镜像右位心患者解剖学及心电图变异特点进行归纳,并探讨其对于介入术者可供借鉴的介入器械和方...     

Acute myocardial infarction in a patient with dextrocardia and situs inversus

We report a case of 54-year-old man who presented to hospital with severe prolonged retrosternal chest pain of anginal nature. Electrocardiogram taken by his general practitioner showed minimal ST elevation in chest leads V1 and V2; there was also marked right axis deviation of P wave (negative in lead I and aVL) and of QRS complexes, together with low voltage in precordial leads V4 through V6 suggestive of dextrocardia. Repeat electrocardiogram with chest and limb leads reversed showed widespread, significant ST elevation in lead I, aVL, and V1 through V5 in keeping with extensive acute anterior myocardial infarction (MI). High cardiac enzymes and troponin level provided further confirmation. The extent of MI in such patients may be underestimated unless dextrocardia is timely recognized and leads reversed. We recommend that for patients with dextrocardia and situs inversus presenting with MI, both chest and limb leads be reversed to reveal the true extent of the infracted area.     

Subclavian stenosis presenting as progressive exertional angina pectoris

Left subclavian stenosis is an uncommon cause of exertional left arm pain. In a patient who presented with exertional chest and left arm pain in an increasing pattern, clinical evaluation disclosed a discrepancy between right and left arm blood pressure. Exercise stress testing with thallium revealed normal myocardial perfusion. Aortic arch and selective angiography revealed a high-grade proximal left subclavian stenosis. Subclavian angioplasty was performed with complete resolution of symptoms. This case demonstrates that ischemic left arm pain due to subclavian stenosis can present as accelerated angina, and highlights the importance of determining blood pressure in both arms in routine evaluation of patients at risk for atherosclerosis.     

Angina pectoris associated with dextrocardia and situs inversus (case report)

A case of angina pectoris with pain radiating to the right arm is reported in an individual with dextrocardia with situs inversus.     

A study of precordial leads in subjects with congenital dextrocardia and situs inversus viscerum

The chest leads of seven persons with congenital dextrocardia and situs inversus viscerum were studied. None of the seven showed any clinical evidence of heart disease. One subject, however, because she had systolic hypertension, was believed to be potentially abnormal, and was considered separately from the other six. The standard leads of this one subject were normal, but she had inverted T waves in CF_1–4 and diphasic T waves in CF₅ and CF₆. The data indicate that the chest leads of a person with congenital dextrocardia and situs inversus are approximately identical with those of an individual whose heart is on the left side, provided the technique of making the leads is altered to conform to the dextro-position of the heart.     

Negative P wave in lead I due to right atrial enlargement and displacement of the heart in the chest

Two cases of a negative P wave in lead I are presented. In both there were signs of a right atrial overloading and the heart was displaced to the left side of the chest due to left pneumonectomy in one case, and to a destroyed lung in the other. The anticlockwise rotation of the heart and the right atrial enlargement are suggested as being contributory factors to the inversion of P wave.     

Colon in the Chest: An Incidental Dextrocardia: A Case Report Study

Diaphragmatic injury is an uncommon traumatic injury (<1%). Although most diaphragmatic injuries can be obvious (eg, herniation of abdominal contents on chest radiograph), some injuries may be subtle and imaging studies can be nondiagnostic in many situations. Patients with diaphragmatic hernia either traumatic or nontraumatic may initially have no symptoms or signs to suggest an injury to the diaphragm.Here, we report a case of a 75-year-old woman diagnosed with irritable bowel syndrome –associated dominant constipation, presented with shortness of breath, cough, expectoration, tachycardia, and chest pain. Dextrocardia was an incidental finding, diagnosed by electrocardiography, chest radiograph, and CT chest. Parts of the colon, small intestine, and stomach were within the thorax in the left side due to left diaphragmatic hernia of a nontraumatic cause. Acquired incidental dextrocardia was the main problem due to displacement of the heart to contralateral side by the GI (gastrointestinal) viscera (left diaphragmatic hernia).The patient was prepared for the laparoscopic surgical repair, using a polyethylene mesh 20 cm to close the defect, and the patient recovered with accepted general condition. However, 5 days postoperative, the patient passed away suddenly due to unexplained cardiac arrest.Intrathoracic herniation of abdominal viscera should be considered in patients presented with sudden chest pain concomitant with a history of increased intra-abdominal pressure.     

Dextrocardia and Wolff-Parkinson-White syndrome. Electrocardiographic diagnosis

A patient affected by dextrocardia and WPW syndrome with atrio-ventricular bypass connecting the left sided atrium to the left ventricle (located to the right) is described. Signs of organic heart disease were not present. Electrocardiogram showed, in addition to typical features of ventricular pre-excitation, a QS pattern in leads V4-V6. During exercise testing the pre-excitation disappeared and the electrocardiogram recorded with inverted peripheral cables and right precordial leads, did not show alterations. The analysis of this case and of another previously published suggests that a QS pattern in left precordial leads is highly suggestive for dextrocardia, even in presence of ventricular pre-excitation.     

Combined valvular disease with the scimitar triad: a case report

A case of combined valvular disease with the scimitar sign is reported. A 48-year-old woman was admitted to our hospital for treatment of congestive heart failure due to combined valvular disease following an upper respiratory infection. Chest radiography revealed hypoplasia of the right lung, dextroposition of the heart and a curved vascular opacity adjacent to the right cardiac border having the appearance of a scimitar sign. The latter was better demonstrated by chest tomography. A lung scan showed a marked decrease in perfusion of the right lung. A CT scan of the thorax revealed hypoplasia of the right lung, dextroposition of the heart and an abnormal, curved and thickened right pulmonary vein which drained into a markedly enlarged left atrium. Right heart catheterization demonstrated elevated pressures in the right side of the heart. However, no shunt was demonstrated. A pulmonary angiogram revealed an anomalous pulmonary vein, having the appearance of a scimitar sign draining normally into the left atrium. Only five cases like the present case have been reported in the world literatures. The results in the present case indicate that patients with radiological evidence of the scimitar syndrome should be examined using computed tomography of the chest to rule out the "pseudoscimitar sign."     

Arteria lusoria aneurysm with truncus bicaroticus: surgical resection without restoring blood supply to the right arm

Arteria lusoria, an aberrant or anomalous right subclavian artery, is the most common anomaly of the aortic arch. It may be associated with other congenital anomalies of the heart and great vessels-including, rarely, truncus bicaroticus (a common trunk of both common carotid arteries), and, even more rarely, aneurysmal formation.Herein, we report the case of a 72-year-old man who had both an atherosclerotic aneurysm of an aberrant right subclavian artery and truncus bicaroticus. We resected the aneurysm through a posterolateral thoracotomy and did not restore the distal pulsatile blood supply to the right arm. During long-term clinical follow-up, the patient experienced no arm ischemia or cerebrovascular insufficiency.Aneurysm of arteria lusoria should be suspected in the presence of a right superior mediastinal mass on chest radiographs and should be considered as a cause of new-onset dyspnea, chest pain, or dysphagia. Symptomatic right arteria lusoria aneurysm should be removed promptly after diagnosis. Despite disagreement among investigators regarding the need to restore pulsatile blood flow to the right arm, we recommend reconstructing that flow, when possible.     

Similarities of ergonovine-induced and spontaneous attacks of variant angina.

Ergonovine has been shown to provoke attacks of variant angina, but a question remains whether spontaneous and ergonovine-induced attacks of variant angina are similar. Seven patients with variant angina undergoing cardiac catheterization were studied during transient episodes of spontaneous and ergonovine-induced rest angina with ST-segment elevation. Clinical, electrocardiographic, left ventricular hemodynamic and coronary angiographic observations were made before and repeated after ergonovine (0.05-0.2 mg I.V.). The character and duration of chest pain were similar during both spontaneous and ergonovine-induced episodes. ST-segment elevation (greater than 1 mm) was present inferiorly in three patients, anteriorly in three patients, and both inferiorly and anteriorly in one patient during both episodes. Mean heart rate and systolic arterial pressure changed little, while left ventricular end-diastolic pressure increased significantly during spontaneous or ergonovine-induced attacks. We observed subtotal or total dynamic obstruction in the left anterior descending (three patients), right coronary arteries (three patients) and both arteries in one patient during both attacks. Thus, in selected patients ergonovine-induced attacks of variant angina were remarkably similar to spontaneous episodes.     

Galvanometric potentials of the extremities and of the thorax in congenital dextrocardia

The results indicate that the electrical field of the heart in cases of dextrocardia is, in effect, a mirror image of the electrical field in the normal subject. That excitation reaches the surface of the thorax near the left ventricle later than it reaches the surface of the thorax near the right ventricle, in the human subject, irrespective of the location of these chambers, may be attributed to factors other than the difference in the thickness of the ventricular walls. The one that comes to mind first is the variation in conductivity of the several components comprising the surrounding medium. At present, there is no direct way of measuring the effect of this on electrical phenomena in the human subject, but the fact that the intrinsicoid deflection is abnormally late in midthoracic leads (V₁, V₂, V_E) in cases of right ventricular hypertrophy and right bundle branch block,^{2, 4, 10} and in leads from the left side of the chest in cases of left ventricular hypertrophy and left bundle branch block^{2, 4} suggests, that, however heterogeneous the conducting medium may be, it has no significant influence.     

Relation between the site of origin of ventricular premature complexes and the presence and severity of coronary artery disease

The clinical implications of ventricular premature complexes in patients with coronary heart disease have received increasing interest. It has been suggested that ventricular premature complexes of right ventricular origin have more benign implications than those that originate from the left ventricle. To define more precisely the relation between the site of origin of ventricular premature complexes and the presence and severity of coronary heart disease in patients with a chest pain syndrome, 39 patients with ventricular premature complexes of right or left ventricular contour who were undergoing cardiac catheterization and coronary arteriography for evaluation of chest discomfort were studied. Ninteen patients had left and 17 had right ventricular premature complexes and 3 had both. Of the 19 with left ventricular premature complexes, 15 had coronary artery disease (12 with two or three vessel obstruction and 3 with single vessel obstruction). Four had normal cardiac catheterization studies. Twelve patients had asynergy on ventriculography. The 17 patients with right ventricular premature complexes had similar angiographic findings. Eleven of the 17 had coronary artery disease (8 with triple vessel disease and 3 with isolated obstruction of the left anterior descending coronary artery). Six had normal arteries. Eight of the 11 with coronary artery disease and right ventricular premature complexes also had asynergy. All three patients with both left and right ventricular premature complexes had coronary obstructive disease. These findings indicate that in patients with a chest pain syndrome there is no relation between the site of origin of ventricular premature complexes and either the prevalence or severity of coronary artery disease.     

Coronary-subclavian steal syndrome presenting with chest pain and syncope

The present case is a 68-year-old patient with complaints of chest pain and syncopal attacks during physical activity of the left arm, for the last six months. He had a coronary artery bypass graft operation 10 years ago. Angiographic examination demonstrated total occlusion of the subclavian artery. The subclavian artery was stealing blood from the left anterior descending artery via the left internal mammary artery and from the brain via the left vertebral artery, leading to the diagnosis of subclavian artery steal syndrome; a rare cause of coronary and cerebral ischaemia.