This case report describes in detail the treatment of a patient with post-cardiotomy cardiogenic shock (PCS) combined with dextrocardia. To our knowledge, this is the only case report detailing the combined use of CABG, ECMO and IABP in a patient with dextrocardia. Other reports describe the use of PCI, CABG or ECMO combined with IABP; however, the patient in this case developed severe complications during CABG and was treated with ECMO combined with IABP and was eventually discharged successfully without ECMO-related complications.
Depending on the position of the heart in relation to the internal organs, there are three types of dextrocardia:2mirror image, right-rotated heart and rightward shift of the heart. A mirror image is when the majority of the heart is located on the right side of the chest, in an orientation which mirrors that of the normal heart. A right-rotated heart is located on the right side of the chest with the apical pointing to the right, but the cavity relationship does not form a mirror image inversion. The rightward shift of the heart is mostly caused by secondary conditions, such as compression of the heart to the right by an occupying lesion in the chest, lung, or diaphragm. The incidence of CAD in patients with dextrocardia is similar to that of the general population.1 Thus, dextrocardia does not appear to increase risk for the development of CAD. 3
Mirror-image dextrocardia is a rare condition, and patients presenting with symptoms of chest pain must be examined quickly for acute coronary syndrome (ACS). If previously unknown to the patient or unrecognized in the workup, clinicians are faced with diagnostic challenges in identifying ACS. In this report, the patient had a clear history of dextrocardia and no standard electrocardiogram was obtained during consultation. Physicians often experienced increased operational difficulty in performing CAG and CABG due in the setting of anatomical abnormalities. Patients with perioperative ventricular arrhythmias and CS have a significantly increased postoperative mortality rate, which complicates the diagnosis and treatment process. 4 Zheng Baorong et al. found that advanced age, left main stem lesion, right coronary lesion, emergency surgery, number and sequence of graft vessels, timing of proximal anastomosis, position of fixator, and use of shunt were predictors for hemodynamic instability, ventricular fibrillation, and emergency conversion to ONCAB from OPCAB. 5 MCS can be instituted at different time points in the perioperative pathway depending on the degree of impaired ventricular function and symptom status of the patient. MCS can also be used in the case of intraoperative failure to wean the patient from cardiopulmonary bypass.6AMI-patients with ECMO‐start after CABG had the lowest 30‐day‐survival (40.7%),7 whereas preoperative and intraoperative ECMO‐start was associated with significantly better survival reaching up to 66.7%.8 There are several forms of MCS that can be utilized; for example, IABP, VA-ECMO, and ventricular assist devices (VAD).6 Simultaneous IABP and ECMO therapy is widely applied in cases of CS, which can temporarily replace cardiopulmonary function, rapidly reduce cardiac load, improve hypoxemia, increase systemic blood flow, and achieve hemodynamic stability.9 Although evidence of its survival benefit is limited, this method has a low mortality rate.10
Complication rates following ECMO remain high, and include renal failure, access site or gastrointestinal tract bleeding, stroke, and limb ischemia. Therefore, thorough assessment of the risks and benefits to the patient is essential. In this case, the patient developed CS after intraoperative opening of blood flow, which was though to the patient's advanced age, multiple coronary lesions, ischemia-reperfusion injury, and previous history of arrhythmia. In order to shorten the intraoperative myocardial ischemia time and reduce the risk of myocardial injury, the patient was urgently transferred to OPCAB, but the result was unfavorable. ECMO and IABP were placed urgently, and the patient was hemodynamically stabilized and eventually discharged from the hospital without complications.