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

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,.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 (,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.

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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 longterm 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 allcause 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

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

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.

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History of past illness

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).

Your grandchild, Little Red Riding Hood, replied the wolf, counterfeiting4 her voice; who has brought you a cake and a little pot of butter sent you by mother.

Personal and family history

No family history.

Physical examination

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Imaging examinations

When Cynthia arrived for work the next morning, Patricia, the store manager, asked her to come to the small room in back of the store that served as an office. Cynthia wondered if she had done something wrong or left some part of her job incomplete3 from the day before. She was concerned and confused.

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).

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

TREATMENT

The patient presented to the outpatient facility with atrial fibrillation.

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.

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 Osaturation 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,Osaturation 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 Osaturation was 95%.At 20 h,the blood pressure was 172/94 mmHg,heart rate was 69 beats/min,Osaturation was 97%,and the blood pressure was 135/68 mmHg.

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.

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 (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[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).

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.

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.