12: Modifications of V-V ECMO in Situs Inversus Totalis - A Rare Case Report

Introduction: Situs Inversus Totalis is a rare condition occurring in every 10,000 to 25,000 individuals, where proper folding of the heart and rotation of gut are reversed. It is associated with congenital heart disease (3-9%) and other vascular abnormalities1. Vascular access needs to be modified for ECMO due to mirror imaging of vascular structures and possible double or right IVC 2. Methods: We report here a rare case and modifications done for V-V ECMO for a community acquired pneumonia with empyema with refractory hypoxemia. A 41-year-old male presented with fever, cough shortness of breath. Chest X Ray showed bilateral infiltrations(R>L) with dextrocardia. CT chest and abdomen showed Situs Inversus Totalis with mirror imaging of thoracic and abdominal organs. He was intubated on admission to ICU, had drainage of empyema and later underwent 2 sessions of prone ventilation without any good response. In view of refractory hypoxemia, V-V ECMO was initiated. Echocardiography was modified for dextrocardia and windows obtained on right side. Rotations done only clockwise to maintain left right spatial relationships and it did not show any major intra cardiac abnormalities. ECMO was modified with access cannula in left femoral vein which is in continuation with IVC entering to left atrium (physiological right atrium). Return cannula was inserted in left internal jugular vein entering left atrium. Right sided ECG monitoring was done for dextrocardia. He required bronchoscopy in view of recurrent right lung collapse, which showed anatomical right lung as bilobed and left lung as trilobed with trachea more in line with left main bronchus. Later he underwent tracheostomy on D4 of ECMO. ECMO was weaned off after 9 days and he was discharged after 26 days of hospital stay. Conclusion: Identifying anatomical challenges and modifying the management accordingly are required for successful ECMO outcomes in Situs Inversus Totalis.