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| CASE REPORT |
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| Year : 2017 | Volume
: 15
| Issue : 3 | Page : 237-239 |
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An unusual cause of acquired cardiac dextroposition
Simon Rajaratnam1, Anjali Bhatt1, Suchita Chase2, Oommen George3
1 Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
2 Department of General Surgery, Diabetes and Metabolism, Christian Medical College, Vellore, India
3 Department of Cardiology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| Date of Web Publication | 7-Aug-2017 |
Correspondence Address:
Simon Rajaratnam
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_49_17
Cardiac dextroposition is the horizontal displacement of the heart into the right hemithorax. We present a case with an unusual cause of cardiac dextroposition. A 75-year-old, morbidly obese woman on regular follow-up for diabetes, hypertension, and ischemic heart disease presented with complaints of a persistent cough. Her chest X-ray showed elevation of the left dome of the diaphragm and shift of the mediastinum to the right which was a new finding as compared to her previous chest X-ray taken in April 2012. Subsequent radiological examination revealed the presence of a well-defined, fat-containing mass in the left hypochondrium displacing the stomach, spleen, and transverse colon downward. She was taken up for laparotomy, and a 2 kg well-circumscribed intraperitoneal tumor was excised from the left hypochondrium. The biopsy showed a well-differentiated liposarcoma. New-onset cardiac dextroposition is usually secondary to pathology in the lungs or the pleura or the diaphragm. An intra-abdominal tumor causing cardiac dextroposition has not been reported so far.
Keywords: Cardiac dextroposition, dextrocardia, liposarcoma
How to cite this article:
Rajaratnam S, Bhatt A, Chase S, George O. An unusual cause of acquired cardiac dextroposition. Curr Med Issues 2017;15:237-9 |
| Introduction | |  |
Cardiac dextroposition is the horizontal displacement of the heart into the right hemi thorax. Dextrocardia, on the other hand is a condition where the cardiac apex is displaced to the right side due to a rotation on its own axis. We present an unusual cause of cardiac dextroposition.
| Case Report | | |
A 75-year-old morbidly obese woman (body mass index 34 kg/m 2) on regular follow-up for diabetes, hypertension, and ischemic heart disease came for her routine checkup in October 2012. She complained of a persistent cough for 10 days. She had no abdominal symptoms. Clinical examination was unremarkable.
Earlier, in April 2012, she came in with new-onset atrial fibrillation. Coronary angiogram at that time revealed triple vessel disease; there was no distortion of cardiac anatomy. She responded well to medical treatment. Her chest X-ray also showed no abnormality [Figure 1]. | Figure 1: Chest X-ray (April 2012) showing the heart in its normal location.
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Investigations
Her current X-ray [Figure 2] revealed elevation of the left dome of diaphragm and shift of the mediastinum to the right; this was new as compared to her previous chest X-ray taken in April 2012. Ultrasound examination revealed an ill-defined lipomatous mass in the left hypochondrium. Computed tomography scan confirmed the presence of a large lipomatous, well-defined vascular mass in the left hypochondrium [Figure 3] measuring 20 cm × 18 cm × 12 cm in size. The mass was displacing the stomach, spleen, and transverse colon downward. There was no associated lymphadenopathy or evidence of local or distant metastasis. | Figure 2: Chest X-ray (October 2012) showing elevation of the left dome of diaphragm and displacement of the heart to the right.
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 | Figure 3: Computed tomography scan (October 2012) showing a large lipomatous tumor occupying the left hypochondrium.
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Treatment
She underwent laparotomy on November 02, 2012, and a large well-circumscribed intraperitoneal lipomatous mass was found within the left hypochondrium. The tumor was radically excised and it weighed around 2 kg. Histopathology revealed a well-differentiated well differentiated type of liposarcoma with focal stromal sclerosis. Although there is no consensus on management, radical excision of the primary tumor is the treatment of choice. She was reviewed by the multidisciplinary team and was kept on close follow without any adjuvant therapy.
Outcome and follow-up
Following surgery, the heart did not return to its normal position. The patient, however, remained asymptomatic and was periodically being reviewed in the outpatient clinic. In January 2017, she came back with tumor recurrence at the same site and quickly succumbed to complications related to disease progression.
| Discussion | | |
Simple horizontal displacement of the heart into the right hemithorax is called cardiac dextroposition. This should be differentiated from dextrocardia, where the heart rotates on its own axis, thereby causing displacement of the cardiac apex to the right side.[1] Unlike cardiac dextroposition, dextrocardia can be associated with inversion of other internal organs called “situs inversus.”
Causes
Cardiac dextroposition may be a congenital malformation or it could be acquired later in life.[2] Common causes of congenital dextroposition include deformities of the chest wall, deformities of the diaphragm (E.g. diaphragmatic hernia, and hypoplasia of the right lung).[3],[4],[5],[6] Congenital cardiac dextroposition is often associated with atrioventricular canal defects. Acquired cardiac dextroposition is commonly seen following pneumonectomy, eventration or paralysis of the left hemidiaphragm, or pneumomediastinum.[7] A large intra-abdominal tumor can cause displacement of the heart due to pressure on the overlying diaphragm. This is being reported for the first time in literature.
Diagnosis
Patients with cardiac dextroposition are usually asymptomatic. Routine physical examination reveals the cardiac impulse (cardiac apex) closer to the sternum. Percussion of the heart borders confirms displacement of the heart to the right.
Chest X-ray (posteroanterior view) shows the cardiac silhouette displaced the right. This may be associated with chest wall deformities or other pathologies in the lungs and the diaphragm. There are no electrocardiogram changes which are specific for this condition. Cardiac magnetic resonance imaging or cardiac catheterization will confirm normal cardiac anatomy.
| Learning Points | | |
- Cardiac dextroposition needs to be differentiated from dextrocardia
- Cardiac dextroposition can be either a congenital or an acquired pathology
- Congenital lesions are usually associated with cardiac or pulmonary anomalies
- Acquired lesions are associated with lung or diaphragmatic disease
- Large intra-abdominal tumors can cause pressure, and displacement of the diaphragm can be mistaken for a benign condition called “eventration of the diaphragm”
- All patients with “eventration of the diaphragm” should undergo ultrasound screening to rule out infradiaphragmatic pathology
- Liposarcomas are known to grow to a very large size. They quite often occur in the extremities and in the retroperitoneal region
- Unlike other tumors, well-differentiated liposarcomas have a good prognosis.
Financial support and sponsorship
Nil.
Conflicts of interets
There are no conflicts of interest.
| References | | |
| 1. | Rogel S, Schwartz A, Rakower J. The differentiation of dextroversion from dextroposition of the heart and their relation to pulmonary abnormalities. Dis Chest 1963;44:186-92.  |
| 2. | Hollendonner WJ, Pastor BH. Dextroposition of the heart simulating congenital dextrocardia. Am J Med 1956;20:647-50. |
| 3. | Morgan JR, Forkar AD. Syndrome of hypoplasia of the right lung and dextroposition of the heart: “Scimitar sign” with normal pulmonary venous drainage. Circulation 1971;43:27-30. |
| 4. | Abdullah MM, Lacro RV, Smallhorn J, Chitayat D, van der Velde ME, Yoo SJ, et al. Fetal cardiac dextroposition in the absence of an intrathoracic mass: Sign of significant right lung hypoplasia. J Ultrasound Med 2000;19:669-76. |
| 5. | Wang Y, Yang X, Dong L, Shu X. A curious case of cardiac dextroposition. Eur Heart J 2014;35:1185. |
| 6. | Haththotuwa HR, Dubrey SW. A heart on the right can be more complex than it first appears. BMJ Case Rep 2013;2013. pii: Bcr2013201046. |
| 7. | Malish RG, Shmorhun DP. Dextroposition of the heart. Mil Med 2007;172:7-9. |
[Figure 1], [Figure 2], [Figure 3]
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