A 76-year-old Japanese female patient had been diagnosed with situs inversus totalis 30 years ago and had since experienced no symptoms of her condition. She had chest pain with physical effort, and coronary angiography was performed. Coronary artery disease of 3 vessels was revealed: the left anterior descending artery (LAD), left circumflex brunch (LCx), and right coronary artery (RCA). She was scheduled to undergo elective CABG. The results of a preoperative chest X-ray were almost within normal limits except her heart was directed to the right. A preoperative electrocardiogram (ECG) was conducted with chest leads in their normal positions; it showed a negative P wave in the I and aVL leads and a positive P wave in the aVR lead, which is a typical right-axis deviation pattern (Fig. 1a). Another ECG was then conducted with the placement of the right lead reversed, which showed ST depression in the I, aVL, V5, and V6 leads, and a negative T wave in the II, III, aVf, and V4-6 leads (Fig. 1b). Preoperative physical examination and evaluation did not reveal any other significant findings.
In the operating room, the position in which the ECG leads were applied was reversed. Other standard monitoring methods were applied, including right radial arterial cannulation. Anesthetic induction was performed with propofol/fentanyl, remifentanil, and rocuronium. She was intubated with a tracheal tube, and pulmonary artery catheterization was performed via the left internal jugular vein using a Swan-Gants catheter (Edwards Lifesciences, USA) with the tip placed at the left pulmonary artery. Catheterization was performed successfully and uneventfully. A postoperative chest X-ray revealed that the pulmonary artery catheter was maintained as the mirror image of its normal position (Fig. 2).
A transesophageal echocardiography (TEE) probe was introduced without difficulty, and intraoperative TEE images were recorded. In this patient, a different angle was needed to acquire the desired views because of her atypical anatomy. Midesophageal (ME) 4-chamber and transgastric short-axis views, which are obtained near 0° in normal hearts, were obtained with the left ventricle on the left side of the TEE screen, which is the inverse of the normal TEE view, i.e., inverted 180° (Fig. 3). The ME commissure view, which is normally obtained at 60°, was obtained at 120°. The ME 2-chamber view was obtained at 90° as with the typical anatomy (Fig. 4). The ME long-axis view, normally found at 120°, was obtained at 60°.
The bicaval view was obtained at 90° while rotating the probe to the left in the direction of the right atrium (Fig. 5). The aortic valve short-axis view, normally found at 30–40°, was obtained at 140–150° (Fig. 6). The aortic valve long-axis view, normally found at 120°, was obtained at 60° (Fig. 7). These views were best obtained at a probe angle which differed by 180° from the typical probe angle.
The preparations were completed, and the cardiac surgery was then started. After median sternotomy, the right internal thoracic artery (RITA) and left internal thoracic artery (LITA) were harvested; the RITA was anastomosed to the LAD, the free LITA was anastomosed to the obtuse marginal branch and ascending aorta, and the saphenous venous graft was anastomosed to the RCA. The operating surgeon was on the left side of the patient during the procedure, and the operation was performed without complications. After surgery, the patient was transferred to the intensive care unit, extubated after 4 h of mechanical ventilation, and discharged without complications. The patient was stable during and after the operation. The patient was transferred to the general ward after 4 days in the intensive care unit and discharged on day 17 after the surgery without any complications.