Dextrocardia with asymptomatic right atrial appendage aneurysm: a case report.

Right atrial appendage aneurysm (RAAA) is rarely encountered with variable intracardiac anatomy. We report a case of asymptomatic RAAA in a patient with dextrocardia and anomalous origin of RCA from left coronary sinus which was treated successfully by CABG and the aneurysm was completely excised.

Introduction

Dextrocardia is a cardiac positional anomaly in which the heart is located in the right hemithorax with its base‐to‐apex axis directed to the right and caudad and may occur independently or as part of situs inversus 1. These patients have variable intracardiac anatomy depending upon their situs and types of segmental connections 2.

Right atrial appendage aneurysm (RAAA) is rare finding with less than 20 cases reported in the literature. Some patients are asymptomatic and diagnosed incidentally while some present with palpitation and dyspnea 3, 4. We report an incidental RAAA in a patient with dextrocardia and coronary artery disease (CAD).

Case Report

A 53‐year‐old male with acute ST elevation (STEMI) (Fig. 1) was admitted for primary percutaneous coronary intervention (PCI). Physical examination was indicative of dextrocardia; the apex of the heart was present in the sixth intercostal space on the right side, lateral to the midclavicular line. Chest X‐ray showed a right‐sided cardiac silhouette with cardiomegaly and right gastric bubble (Fig. 2), supporting the diagnosis.

Figure 1

Electrocardiogram showing acute ST elevation myocardial infarction.

Figure 2

Chest X‐ray (posterior anterior view) of a 53‐year‐old man showing dextrocardia, with the cardiac apex pointing to the right.

Left heart catheterization and selective coronary angiography were performed via the right femoral artery without any complication which showed two vessel diseases (lesion in LAD and 50% stenosis in LCX and left main coronary artery) along with abnormal origin of RCA from left coronary sinus without significant lesion (Fig. 3). Normal bilateral coronary arteries were also shown. Due to these findings and technical difficulty, primary PCI was not performed and the patient was candidate for coronary artery bypass graft (CABG) surgery.

Figure 3

CAG findings indicating subtotal lesion in LAD and 50% stenosis in LM and LCX along with abnormal origin of RCA from left coronary sinus without significant lesion.

Transthoracic echocardiography revealed a large echo‐free cavity lateral of right ventricle with anticontrast inside it and compressive of RV and contiguous with main body of right atrium (Fig. 4). Transesophageal echocardiography showed a right atrial appendage aneurysm (RAAA) and atrial structures. The size of aneurysm was 11.60*3.20 cm. Contrast study showed better visualization of RAAA and its connection with RA.

Figure 4

(A) Transthoracic echocardiography from apical four‐chamber view demonstrating a large echo‐free cavity lateral of right ventricle with anticontrast inside it and compressive of RV and contiguous with main body of right atrium. (B) Transesophageal echocardiography showed a right atrial appendage aneurysm and atrial structures. Contrast study showed better visualization of RAA and its connection with RA. (C) Transesophageal echocardiography demonstrating combination of dextrocardia and RAAA.

The patient underwent CABG, and the RAAA was completely excised and repaired.

Discussion

Patients with dextrocardia usually have similar incidence and presentation of CAD as the general population 5. Anomalous coronary arteries including anomalous origin of RCA from left coronary sinus are previously reported with successful PCI 6. Although it is reported that dextrocardia accompanies with variable intracardiac anatomy and anomalies 2, there are no reports regarding RAAA in dextrocardia.

We report a case of asymptomatic RAAA in a patient with dextrocardia and anomalous origin of RCA from left coronary sinus which was diagnosed incidentally. Surgical resection is recommended for symptomatic patients and those with enlarging aneurysm in serial imaging. Anticoagulation is indicated for asymptomatic patients to prevent adverse embolic events, and a combination of cardioversion and antiarrhythmic drugs is used to control associated dysrhythmia in an attempt to convert to a sinus rhythm 3. CABG, if indicated for CAD, could be performed successfully.

Authorship

HS: diagnosed the patient. NR: performed the echocardiography. HS and NR: contributed to the first writing of the manuscript. PA: contributed by doing the final editing and translation. NM: contributed to the idea and the editing the content.

Conflict of Interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Patient Consent

A written informed consent was obtained from the patient for publication of the submitted article and images.