All right sided hearts are not Dextrocardia

M. Mubeena Anjum

Department of Emergency Medicine, Kauvery Hospital, Salem, India

Case Presentation

A 57/M, known to indulge in smoking and alcohol, presented to the ER with chief complaints of breathlessness and cough for the past four days.

He complained of worsening breathlessness, for the past four days, present at rest and on lying down, also at night, forcing him to sit up. He also had swelling in both legs. He had intermittent dry cough also for the same duration.

No H/O fever, chest pain, abdominal pain, reduced urine output, or loss of consciousness

Past history

Diabetes Mellitus and Systemic Hypertension for the past ten years, on regular medications.

He was diagnosed and treated with Chronic Obstructive Pulmonary Disease (COPD) and severe Pulmonary Artery Hypertension (PAH), and also as dextrocardia for the past seven years

H/O abdominal surgery underwent seven years back-details not available.

No known medical allergies, last meal was the previous night, no relevant family history.

Clinical findings

On arrival at ER: BP, 140/80 mmHg; PR, 120/min; RR, 36/min; SpO2; 48% RA improved to 85% with oxygen by face mask at 8 L/min.

Systemic examination

Respiratory examination indicated reduced intensity of breath sounds, with wheeze and crepitations on both sides

Other system examinations- NAD.

Investigations

ABG

Initial Blood Gas values

pH, 7.20; pCO₂, 96; pO₂, 56; lac, 1.0; HCO₃, 37.5, SO₂, 81.2 showed severe respiratory acidosis, type 2 respiratory failure. He was started on NIV, nebulization, steroids, antibiotics, and other supportive measures.

ECG showed sinus tachycardia, peaked P in Lead II and deep S wave in V1, suggesting RAH and RVH

Point of Care Ultrasound (POCUS)

Echo showed dextroverted heart, severe PAH, mild TR, dilated RA and RV, concentric LVH, mild LV dysfunction and grade 2 diastolic dysfunction.

Lungs- bilateral A lines, left minimal pleural effusion.

Chest X-ray

Bilateral lower zone haziness, elevated left hemidiaphragm, mediastinal shift to the right and cardiac silhouette, with the apex to the right side mimicking dextrocardia.

CT chest

CT chest revealed diaphragmatic hernia with large defect of 15-18cm and herniation of fat, stomach, with organo- rotation of spleen and splenic flexure.

Heart is pushed to the right side, minimal left pleural effusion, with subpleural atelectasis of left lower zone.

Definitive management

He was planned for laparotomy. Intraoperative findings showed diaphragmatic eventration for which diaphragmatic plication was done.

Postoperative management including NIV support, bronchodilator, antibiotics and other supportive measures. He improved symptomatically and was discharged 10 days later

On Discharge: BP, 140/90 mmHg; PR, 82/min; SpO2, 89% room air.

Discussion

Dextrocardia is a congenital condition in which the heart is abnormally located in the right hemithorax with its atrioventricular axis pointing towards the right. It is mostly diagnosed incidentally. ECG changes include right axis deviation, inverted p wave, QRS complex and T wave in lead 1- global inversion- and absent R wave progression in precordial leads. Chest X-ray can be diagnostic as anteroposterior relationships of various parts of the heart are normal but the left to right orientation is reversed, which can be easily diagnosed by right-sided aortic notch and stomach bubble in case of situs inversus. The right diaphragm will be lower than left as the dextroverted cardiac apex pushes down the diaphragm.

Our patient did not have any of these features of a congentital heart disease.

Dextroposition is the term used when the heart is pushed to the right side of the chest due to extra cardiac etiologies like right pulmonary hypoplasia (scimitar syndrome), right pneumonectomy or left side chest pathologies like diaphragmatic hernia or other space occupying lesions.

In our case, it was misdiagnosed as dextrocardia just by misinterpreting the right sided heart, which was actually due to heart pushed by the expanding diaphragmatic hernia with its content.

Acquired diaphragmatic hernia is mostly due to trauma, but may be iatrogenic or spontaneous. In our case it could have been due to the abdominal surgery he underwent years ago.

In our case, ECG was not suggestive of dextrocardia, POCUS suggested dextroposed heart, CXR – much elevated left hemidiaphragm, CT showed diaphragmatic defect, later intraoperative confirmation of diaphragmatic eventration done.

Key points

All right-sided hearts aren’t dextrocardia, it can be dextroposition.

All elevated left hemidiaphragm aren’t diaphragmatic hernia, it can be diaphragmatic eventration.

Dr. M. Mubeena Anjum

Consultant in Emergency Medicine

All right sided hearts are not Dextrocardia