P067: ANESTHETIC MANAGEMENT AND TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR ATRIAL FIBRILLATION IN PATIENT WITH DEXTROCARDIA
Alex Hugues, MD; Jean P Lamour; Edward Parker, MD
HCA Westside Regional Medical Center
Introduction/Background: Transesophageal echocardiography (TEE) is the gold standard monitoring for atrial fibrillation ablations. Preoperatively it is utilized to visualize the left atrial appendage(LAA) and identify any potential blood clots which could pose a risk during the procedure. There are many other benefits for TEE during ablations such as identifying proper anatomy to guide the proceduralist, especially during septal crossing. TEE also provides accurate assessment of the left atrium which guides catheter placement and provides post-procedural visualization to rule out pericardial effusion. Accurate visualization and transseptal guidance is paramount for ablation procedures, patients presenting with dextrocardia it is important for a clinician to understand orientation since the heart is a mirror image of a normal. Dextrocardia is a cardiac abnormality in which the heart is rotated to the right hemithorax with the apex pointing towards the liver. Dextrocardia with situs inversus is important to differentiate from isolated dextrocardia because the former means all of the patient's organs are rotated and become a mirror image of the typical normal. It is important to perform a thorough TEE examination on patients with Dextrocardia as they are usually accompanied with other cardiac abnormalities such as VSD, PDA and ASD which can complicate procedures that require transseptal puncture such as atrial fibrillation ablations.
Case Presentation/Methods: Patient is a 64 male with a past medical history of hypertension, uncontrolled atrial fibrillation and dextrocardia. No other pertinent medical conditions and denies gastrointestinal and respiratory symptoms. Post intubation 3D TEE view of the left atrial appendage (LAA) is obtained to rule out thrombus, due to the rotation of the heart to the right hemithorax LAA views was obtained at the mid-esophageal mid axis view but at 120-150 degrees rather than the 30-60 degrees. Due to patients anatomy views were obtained as mirror imaging of a normal heart position in order to guide proceduralists and decrease the risk of perforation which can lead to pericardial effusion.
Discussion/Conclusion: The initial presentation in a patient presenting with dextrocardia can be challenging to an unsuspecting clinician. Thorough preoperative evaluation is necessary in patients with high clinical suspicion but also it is important to have an experienced clinician who can differentiate normal TEE views and differentiate from a patient who is presenting with dextrocardia. Standard cardiac TEE views start with a 4 chamber view obtained at 0 degrees but in a patient with dextrocardia it would be obtained at 180 degrees because of the mirror image properties. The likelihood of a patient having septal defects such as VSD, ASD or transpositioning of great vessels is increased with dextrocardia without situs inversus so a thorough examination from an experience clinician is important in order to identify anomalies which will not only in the procedure but also for anesthetic management of the patient.