Interact CardioVasc Thorac Surg 2009;9:698-702. doi:10.1510/icvts.2009.216317
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Congenital |
Should you stand on the left or the right of a patient with dextrocardia who needs coronary surgery?
Rasheed A. Saada,*,
Adel Badrb,
Andrew T. Goodwina and
Joel Dunninga
a Department of Cardio-thoracic Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
b Department of Cardiac Anaesthesia, James Cook University Hospital, Middlesbrough, UK
Received 8 July 2009;
accepted 13 July 2009
*Corresponding author. Tel.: +44 1642 850850; fax: +44 1642 854613.
E-mail address: rasheed.saad{at}doctors.net.uk (R.A. Saad).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which side of the operating table you should stand on when carrying out surgical revascularization on a patient with dextrocardia. Altogether 40 papers were found using the reported search, of which 19 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers are tabulated. The side on which the operating surgeon stood was mentioned in 20 out of the 24 cases. Surgery was carried out from the conventional right side of the patient in 5 cases, while in 10 cases, it was carried out from the left side. The surgeon needed to switch sides to facilitate surgery in three cases. In addition, the right internal mammary artery (RIMA) was anastomosed to the left anterior descending artery (LAD) in 16 cases. Of these, surgery was carried out from the left side in 11 cases. The left internal mammary artery (LIMA) to LAD anastomosis was carried out in two cases, one of which was a free LIMA graft. In six cases, only vein grafts were used. Fourteen cases were carried out using cardiopulmonary bypass while 10 cases were carried out as off-pump cases with one conversion. The majority of patients were operated on from the left of the table. More cases were performed with the RIMA as the conduit of choice to the LAD.
Key Words: Dextrocardia; Coronary revascularization
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients with dextrocardia having CABG] is [the left] or [the right] the best side to stand on in order to facilitate [optimal surgery?]
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3. Clinical scenario
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We were referred a 71-year-old gentleman with dextrocardia, situs inversus and triple-vessel disease for CABG.
The chest was entered through a median sternotomy. The heart was exactly the mirror image of a normally positioned heart (Fig. 1). The right internal mammary artery (RIMA) was harvested as a pedicle graft. Standard cardiopulmonary bypass was established between the right atrium and the ascending aorta with the surgeon on the right. The distal vein graft anastomoses to the posterior descending (PDA) and obtuse marginal (OM) arteries were performed with the operating surgeon standing on the right of the patient while the RIMA anastomosis to the left anterior descending artery (LAD) was carried on from the left side.
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Fig. 1. Photo of patient's heart with dextrocardia (cannulated on the left). The patient's head is to the bottom of the photo.
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After the case you wonder how other surgeons had approached this situation and resolve to search the literature.
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4. Search strategy
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Medline 1950 to May 2007 using OVID interface [Coronary artery bypass grafting.mp] AND [Dextrocardia.mp].
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5. Search outcome
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Forty papers were found using the reported search. Twenty relevant papers reported 24 cases of revascularization surgery in patients with dextrocardia. These are presented in Table 1.
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6. Results
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A total of 20 papers reporting 24 cases of surgical myocardial revascularization. Four case reports did not clearly mention the side that the operating surgeon stood on. Two of these cases were among the first reported cases [2, 3]. In others, surgery was carried out from the conventional right side of the patient in 5 out of the 24 cases. However, 10 out of the 24 cases were performed with the operating surgeon standing on the left side of the patient. In 3 cases, the operating surgeon had to switch sides in order to facilitate performance of the surgery.
Fourteen cases were performed utilizing CPB. Of which, one case had to be performed on CPB as surgery involved thoracic aorta and valvular procedures. Off-pump surgery was employed in 10 cases. Only one of the 10 cases [10] was converted to on-pump due to haemodynamic instability while performing the PDA anastomosis. Total arterial revascularization was carried out in four cases [11, 14, 16, 17].
Bonde and Campalani [10], and Pego-Fernandes et al. [19] strongly recommended performing the surgery from the left side. Naik et al. [7] also felt that operating from the left side greatly facilitates the surgery. However, Karimi et al. [18] advocated operating from the right side as he was comfortable doing two cases from the right side. Interestingly, Chakravarthy et al. [21] reported a series of two cases. The first case was performed from the conventional right side while in the second case, the proximal anstomoses were performed from the right side while the distal anastomoses were carried out from the opposite side. He concluded that surgery in such patients poses extra technical problems even if the surgeon stands on the left side of the patient. The same conclusion was reached by Ennker et al. [17] who did his surgery from the left side of the patient.
Abdullah and Mazalan [13] and Chakravarthy et al. [21] reported difficulty with the exposure of the PDA and its subsequent anastomosis. They both experienced hypotension that was managed with fluid administration and inotropic support. Bonde and Campalani [10] had to convert their case to on-pump to facilitate the PDA anastomosis. Chakravarthy et al. [21] did both cases off-pump but envisaged that on-pump surgery would pose technical problems with caval and retrograde cardioplegia cannulation. Totaro et al. [5] had difficulty in cannulation of the inferior vena cava (IVC) due to the extreme rotation of the right atrium and advised femoral venous cannulation as a good option in such patients. No other adverse events were reported from the rest of the on-pump group. Naik et al. [7] felt that due to the arrangement of the heart chambers, there would an advantage in placing the CPB machine opposite to the surgeon, but they did not find this particularly helpful and recommended the position the surgical team is most comfortable with.
In 16/24 cases, the RIMA was the conduit of choice to the LAD. Only two papers reported the use of left internal mammary artery (LIMA) to the LAD [6, 14]. Tabry et al. [6] used free LIMA, while Kuwata et al. [14] utilizing full skeletinization of LIMA, managed to anastomose the in-situ LIMA to the LAD. Chakravarthy et al. [21] in their first case had to do more proximal dissection and skeletonize the LIMA pedicle to allow the in-situ LIMA to LAD anastomosis. A standard RIMA to LAD anastomosis was performed in the second case.
Poncelet et al. [16] harvested both ITAs and found the fully dissected LITA was too short to revascularize the LAD territory while the RITA was anastomosed comfortably to the distal third of the LAD with perfect alignment on the anterior surface of the heart.
Five cases were carried out before the frequent use of IMA became a standard practice, while Abdullah and Mazalan [13] opted for all venous conduits in the setting of high-risk surgery.
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7. Clinical bottom line
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The side of the operating surgeon was mentioned in 18 out of the 24 cases. Surgery was carried from the conventional right side in 5 cases, while in 10 cases, it was carried out from the left side. The surgeon needed to switch sides to facilitate surgery in three cases.
The RIMA was anastomosed to the LAD in 16 cases. Of these, surgery was carried out from the left side in 11 cases. The LIMA to LAD anastomosis was carried out in two cases, one of which was a free LIMA graft. In six cases, only vein grafts were used. Fourteen cases were carried out using cardiopulmonary bypass while 10 cases were carried out as off-pump with one conversion.
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Abstract
1. Introduction