Left atrial appendage occlusion in a mirror-image dextrocardia: A case report and review of literature

Abstract

BACKGROUND

In mirror-image dextrocardia, the anterior-posterior position of the cardiac chambers and great vessels is maintained, but the left-right orientation of the abdominal organs is reversed. The abnormal anatomy of the heart poses surgical challenges and problems in dealing with surgical risk and monitoring complications. There are few reports on closure of the left atrial appendage (LAA) in dextrocardia and no reports on the application of enhanced recovery after surgery (ERAS) following LAA occlusion (LAAO) procedures.

CASE SUMMARY

The objective for this case was to ensure perioperative safety and accelerate postoperative recovery from LAAO in a patient with mirror-image dextrocardia. ERAS was guided by the theory and practice of nursing care. Atrial fibrillation was diagnosed in a 77-year-old male patient, in whom LAAO was performed. The 2019 guidelines for perioperative care after cardiac surgery recommend that the clinical nursing procedures for patients with LAAO should be optimized to reduce the incidence of perioperative complications and ensure patient safety. Music therapy can be used throughout perioperative treatment and nursing to improve the anxiety symptoms of patients.

CONCLUSION

The procedure was uneventful and proceeded without complications. Anxiety symptoms were improved.

Key Words: Atrial fibrillation, Dextrocardia, Left atrial appendage occlusion, Music therapy, Enhanced recovery after surgery, Case report

Core Tip: Mirror dextrocardia has typical clinical characteristics. Because of the high prevalence and mortality of atrial fibrillation of patients with mirror dextrocardia, left atrial appendage occlusion has an important role in treatment, which continues to be confirmed. Left atrial appendage occlusion is an ideal choice for patients with atrial fibrillation. Moreover, music therapy can be used throughout perioperative treatment and nursing to improve the anxiety symptoms of patients.

INTRODUCTION

Enhanced recovery after surgery (ERAS) is a multimode, interdisciplinary care model designed to improve perioperative care, including medical care before, during, and after surgery and during rehabilitation. Increasing evidence supports the use of ERAS in surgical patients. ERAS is effective in reducing gastrointestinal infections and hospital stay associated with general colon and rectum surgery. The ERAS Society has been the source of international plans for colorectal, hepatobiliary, urinary, gastric, gynecological, and cardiac surgery groups, and provided evidence-based guidelines for the perioperative treatment and nursing of patients[1-3].

In cardiac surgery, the ERAS model shows that early extubation is safe and feasible, and can significantly shorten electrocardiogram (ECG) monitoring and coronary care unit (CCU) stays. However, the application of ERAS models in cardiac surgery is still at an early stage, and reports in interventional cardiology are limited. Studies have shown that ERAS regimens are feasible and safe in minimally invasive cardiac surgery, and have the potential to significantly improve patient prognosis[4,5].

The ERAS model has characteristics specific to different clinical fields, but the basic concept is common to all fields. The 2019 guidelines for accelerating postoperative rehabilitation of heart surgery include correcting malnutrition before surgery, smoking and drinking cessation, establishing a cardiac preadaptation plan including education, nutrition optimization, sports training, social support, and reducing anxiety, infection prevention, carbohydrate loading (sugar prestorage), establishment of an electronic health platform, etc. The intraoperative care package includes local nasal treatment to eliminate staphylococcus colonization, skin preparation, depilation scheme, dressing changes, prevention of hypothermia, keeping venous access open, rigid sternum fixation, and hemostasis. Whole-process management of patients in the perioperative period includes intensive glycemic control, pain management, delirium screening, drug anticoagulation, early extubation, biomarkers for early identification of high-risk patients with acute kidney injury, and goal-directed recommendations (i.e., blood pressure, cardiac index, systemic venous oxygen saturation, and urine volume). Fluid management therapy is a cooperative multiteam effort, including nutritionists, early cardiac rehabilitation therapists, and physiotherapists.

Left atrial appendage occlusion (LAAO) is a minimally invasive intervention guided by medical imaging equipment[6]. A device is positioned in the left atrial appendage (LAA) by percutaneous venipuncture to prevent thrombi from entering the blood circulation in patients with atrial fibrillation. Medical staff are concerned about the consequences of and low compliance with long-term use of oral anticoagulants and the high risk of bleeding. Therefore, LAAO has been applied as an alternative[7,8]. At present, the two most commonly used LAAO devices worldwide are the Watchman implant system and the Amplatzer cardiac plug. The Watchman device has been approved by Federal Drug Administration as an alternative for stroke prevention and it is the most widely used LAAO closure device[9]. Studies have shown that the effectiveness of LAAO against thrombus formation is similar to that of oral warfarin, and it has advantages in preventing stroke and maintaining quality of life[10-13]. In long-term follow-up, the incidence of both bleeding and stroke decreased significantly. LAAO was also found to be suitable for patients with atrial fibrillation who cannot tolerate oral anticoagulants, have a high risk of bleeding, have anticoagulant contraindications, and for whom anticoagulation did not prevent stroke[14-16]. The Watchman device was also found to reduce the incidence of perioperative complications, hemorrhagic stroke, stroke disability and mortality, cardiovascular events, and all-cause mortality, and to improve clinical outcomes and prognosis[17-20]. With ongoing advances in perioperative care, LAAO will continue to develop as an effective alternative strategy to prevent stroke in patients with atrial fibrillation.

In dextrocardia, the apex of the heart points to or is located on the right side of the chest[21,22]. Using the longitudinal axis of the heart as a reference, dextrocardia can be seen as either situs solitus, in which the abdominal organs are in their normal positions, or situs invertus, in which the abdominal organs are horizontally reversed or “mirrored”[23]. Mirror-image dextrocardia is a rare anomaly, with an incidence of about 1:10,000 in the general population[24]. There have been few published reports of LAAO in patients with dextrocardia, which is surgically challenging because of the anatomical anomalies, surgical risk, and complication monitoring that must be considered[25,26]. There have also been no reports on the application of the ERAS model to LAAO. This case describes our experience with ERAS following the 2019 accelerated cardiac surgery rehabilitation perioperative nursing guidelines for perioperative care of a patient with dextrocardiac LAAO.

CASE PRESENTATION

Chief complaints

The patient presented to the outpatient facility with atrial fibrillation.

History of present illness

The patient reported having experienced occasional palpitations and discomfort without obvious chest tightness and pain, and presented with fluent speech, unclear articulation, hearing loss, and mild activity impairment of the left lower limb.

History of past illness

The patient had a history of cerebral infarction, hypertension, cholecystectomy, prostatic hyperplasia surgery, and fractures of both upper limbs and the left lower limb. Long-term oral aspirin was discontinued in the previous month because of hematochezia.

Personal and family history

No family history.

Physical examination

On presentation, the patient’s body temperature was 37 °C, the pulse was 89 beats/min, respiration rate was 18 breaths/min, blood pressure was 143/76 mmHg, and the numerical rating scale pain score was 0. Twelve-lead electrocardiography revealed atrial fibrillation with a change in the ST-T segment.

Imaging examinations

Twelve-lead electrocardiography revealed atrial fibrillation with a change in the ST-T segment.

FINAL DIAGNOSIS

The diagnosis was arrhythmia, paroxysmal atrial fibrillation, cardiac function New York Heart Association level II, level II very high-risk hypertension, sequelae of cerebral infarction, and visceral inversion (Figure 1).

Figure 1 Details of the surgical procedure. A: Transesophageal echocardiography; B: Dextrocardia (45°); C: Morphology of left atrial appendage; D: Left femoral vein puncture; E: Atrial septum puncture; F: Superior pulmonary vein of guide wire; G: Sheath follow up; H: Auricle not fully exposed; I: Right anterior oblique cardiography; J: Occluder selection; K: Implantation of sealing umbrella; L: Pulling and plugging the closure umbrella; M: Release the closure umbrella; N: Multi angle compression ratio (24%-27%); O: No residual shunt (0°); P: 1.5mm residual shunt (45°); Q: No residual shunt (90°); R: No residual shunt (135°).

TREATMENT

Percutaneous LAAO was performed under general intravenous anesthesia (Figure 1).

OUTCOME AND FOLLOW-UP

After the LAAO procedure, the patient was admitted to the CCU. His vital signs were closely monitored and found to be stable following surgery. At 18 h, the heart rate was 75 beats/min, average blood pressure was 139/80 mmHg, average O₂ saturation was 97%, and the urine volume was 2100 mL. At 19 h, the blood pressure was 197/99 mmHg, the heart rate was 64/min, O₂ saturation was 92%, and the urine volume was 900 mL. Infusion of 0.9% normal saline 250 mL + 10 mg isosorbide nitrate was maintained at 10 mL/h, as advised by the doctor. At 19 h 15 min, the blood pressure was 190/85 mmHg, the heart rate was 64 beats/min, and the O₂ saturation was 95%. At 20 h, the blood pressure was 172/94 mmHg, heart rate was 69 beats/min, O₂ saturation was 97%, and the blood pressure was 135/68 mmHg.

Puncture wounds were treated by finger compression to stop bleeding. If after 20 min no bleeding had occurred, then an elastic bandage was applied for compression. A 1 kg sandbag was applied for 6 h and a right lower limb brake was applied for 12 h. The wound dressing was changed daily. TEE on the first day after the procedure showed that the position of the umbrella was good, and that the residual shunt was about 2 mm behind the lower edge of the umbrella. No procedure-associated complications occurred during hospitalization or in the 12 d after the procedure. Follow-up echocardiography on October 18, 2019, 45 d after the procedure, and November 21, 2019 found that the occluder was in a good position, with a residual shunt of 2 mm around the lower edge of the umbrella. There had been no serious arrhythmia, bleeding, or cerebrovascular accident (Figure 1).

DISCUSSION

Dextrocardia situs inversus totalis is a rare congenital cardiac anomaly[26] in which the relationship of the great arteries is normal or transposed, as in mirror dextrocardia (coordinated cardiac circulation). Uncoordinated cardiac circulation usually shows congenital transposition of great arteries[27]. In patients with mirror dextrocardia, the main challenge for surgeons is the reversal of the whole heart, and in this case, the ECG leads were placed in the mirror mode (i.e., reversed). The fluoroscopy image is reversed horizontally, and the catheter is rotated in the opposite direction from normal[28]. The risks of coronary atherosclerosis and acute myocardial infarction in those with mirror dextrocardia are not different from those in normal individuals.

Anatomical characteristics of LAA

LAA is a remnant of the primitive atrium in the embryo. It has pectinate and trabecular muscle a unique rough endocardium[11]. It usually has three anatomical regions, the mouth, neck, and leaf and a morphology usually described as chicken wing, cactus, windsock, and cauliflower, which are present in different proportions[29,30] and appear different when observed from different angles. Some studies have reported that the LAA regulates pressure and volume load, releases atrial natriuretic peptide and B-type natriuretic peptide, and regulates hemodynamics.

Capacity load

The increase of volumetric load blood pressure after cardiac interventions may be related to excess intraoperative infusion. The left ventricular cardiac ejection fraction of the patient, who weighed 79.8-80 kg, was 56%. Fluid loss was [(4 × 10) + (2 × 10) + (1 × 60)] × 9 = 1080 mL and replenishment was complete within 2 h after the start of anesthesia[31,32]. The volume of fluid replenishment at 1 h was 1080/2 + 110 = 650 mL, with an additional 650 mL at 2 h. After that, a physiological requirement of 110 mL/h was maintained. The patient was given antibiotics (0.9% normal saline 100 mL + cefuroxime 1500 mg), sodium lactate ringer injection 500 mL + 5% glucose, normal saline 500 mL + heparin 5000 U within 2 h after the start of anesthesia. The total of 2100 mL, which was more than needed, may have contributed to the postoperative elevated blood pressure. It was agreed that the total intraoperative fluid given to the patient was not likely to have exceeded 1500 mL.

Nursing guidance by ERAS recommendations

The preoperative nutritional status of the patient was good; he did not smoke or drink. His hemoglobin was 136 g/L, and he was infection-free. An electronic health platform allowed for establishment of a real-time hospital community with an application for those with coronary heart disease to participate in a cardiac preconditioning plan that included education, nutrition optimization, sports training, social support, and anxiety reduction. A self-rating anxiety scale was used to assess the anxiety level of the patient when he was admitted to hospital on August 29. His score was 65, indicating moderate anxiety. International studies have shown that music therapy can improve the mood of patients, promote mental health, and reduce anxiety and depression symptoms[33-35]. Chu et al[36] and others have shown that music therapy can improve anxiety and depression in patients with Alzheimer's disease. Studies in China have shown that five-element music therapy improved the sleep quality of patients with heart failure and anxiety and that Wuxing music combined with Baduanjin had a positive effect on the psychology of patients with poor health status[37,38]. Music therapy was used in the care of this patient. Six pieces of music were selected and played at 8:00-8:30 in the morning and 20:00-20:30 in the evening. The volume was 40-60 DB. On September 6, the SAS score was 46, and the anxiety state had significantly improved. Music therapy was easy to provide and not limited by the venue, and was enjoyed by the patient (Table 1).

Table 1 Nursing procedures guided by the enhanced recovery after surgery model.

Phase	Project	Level of evidence	Recommendation	Remarks
Preoperative	Hemoglobin	IIA, C-LD	Yes	Preoperative measurement of hemoglobin to assist risk stratification
	Albumin	IIA, C-LD	Yes	Preoperative assessment of albumin contributes to risk stratification
	Correcting malnutrition	IIA, C-LD	Yes	Recommend correcting nutritional deficiencies where feasible
	Smoking and drinking	I, C-LD	Yes	Patients were advised to stop 4 wk prior to elective surgery
	Carbohydrate load	IIB, C-LD	Yes	Carbohydrate loading (sugar prestocking) can be performed 2-4 h before general anesthesia
	Infection prevention	IA	Yes	Cephalosporins are recommended for 30-60 min before surgery
	E-health platform	IIA, C-LD	Yes	Establish electronic health education platform
	Cardiac preconditioning program	IIA, B-NR	Yes	These include education, nutrition optimization, sports training, social support, and mindfulness stress reduction training to reduce anxiety
Intraoperative	Implementation care package	I, B-R	Yes	Including local intranasal therapy to eliminate staphylococcal colonization
				Cephalosporins were injected within 60 min before skin incision and redone in cases over 4 h
				Skin preparation, depilation plan, dressing change after every 48 h
	Recovery temperature	III, B-R	No	Avoid high temperature during cardiopulmonary bypass reheating, that is the core temperature should not be > 37.9 °C
	Rigid sternum fraction	IIA, B-R	No	Rigid sternum fraction is beneficial in patients undergoing sternotomy
	Bleeding prevention	I, A	No	Tranexamic acid or amino hexic acid is recommended for cardiopulmonary bypass
Postoperative	Enhanced glycemic control	IIA, B-NR	Yes	Factors of postoperative hyperglycemia: glucose toxicity, oxidative stress, prethrombotic effect, inflammation
	Insulin infusion to treat hyperglycemia	IIA, B-NR	No	Insulin infusion is recommended to treat perioperative hyperglycemia
	Pain management	I, B-NR	No	Prescription of acetaminophen, tramadol, dexmedetomidine, pregabalin, gabapentin, etc.
	Hypothermia	I, B-NR	Yes	Warm blankets, elevated room temperature, heat perfusion and intravenous infusion are recommended for postoperative use
	Delirium	I, B-NR	Yes	At least one delirium screening is recommended for each nursing class
	Anticoagulant drugs	IIA, C-LD	Yes	Drug anticoagulation is recommended to reduce the risk of thrombosis
	Early extubation	IIA, B-NR	Yes	Strategies are recommended to ensure that the tube is extubated within 6 h of surgery
	Acute renal injury	IIA, B-R	Yes	Biomarkers are recommended for early identification of at-risk patients early and guide the reduction of AKI
	Goal-directed fluid therapy	I, B-R	Yes	Goal-directed fluid therapy is recommended to reduce postoperative complications
	Other	Unrated	Yes	Cardiopulmonary bypass, perfusion, mechanical ventilation at low tidal volume, early postoperative enteral feeding and postoperative mobilization are recommended
				It is recommended that the recommendations be adjusted to achieve the goals through multiteam collaboration (dietitians, early cardiac rehabilitation therapists, and physical therapists)

AKI: Acute kidney injury.

CONCLUSION

Mirror dextrocardia has typical clinical characteristics. Because of the high prevalence and mortality of atrial fibrillation of patients with mirror dextrocardia, LAAO has an important role in treatment, which continues to be confirmed[39,40]. LAAO is an ideal choice for patients with atrial fibrillation. The 2019 nursing guidelines for accelerated cardiac surgery recovery optimize the clinical nursing path of patients with LAAO and can reduce perioperative complications and ensure the patient safety. The application of music therapy can reduce patient anxiety and is suitable for the entire process of treatment and nursing care.

ACKNOWLEDGEMENTS

The authors would like to express their gratitude to Wong F, for performance of the transesophageal echocardiography assessment; to Liu YX, for serving as the patient’s anesthesiologist; and to Zheng QQ, who performed language translation activities for the case report.