Situs ambiguus

Situs ambiguus is a rare congenital defect in which the major visceral organs are distributed abnormally within the chest and abdomen. Heterotaxy in general refers to any defect of left-right laterality and arrangement of the visceral organs. This does not include the congenital defect situs inversus,[1] which results when arrangement of all the organs in the abdomen and chest are mirrored, so the positions are opposite the normal placement. Situs inversus is the mirror image of situs solitus, which is normal asymmetric distribution of the abdominothoracic visceral organs. Situs ambiguus can also be subdivided into left-isomerism and right isomerism based on the defects observed in the spleen, lungs and atria of the heart.

Situs ambiguus
Other namesSitus ambiguous, heterotaxy, heterotaxia

Individuals with situs inversus or situs solitus do not experience fatal dysfunction of their organ systems, as general anatomy and morphology of the abdominothoracic organ-vessel systems are conserved. Due to abnormal arrangement of organs in situs ambiguus, orientation across the left-right axis of the body is disrupted early in fetal development, resulting in severely flawed cardiac development and function in 50–80% of cases. They also experience complications with systemic and pulmonary blood vessels, significant morbidity, and sometimes death.[2] All patients with situs ambiguus lack lateralization and symmetry of organs in the abdominal and thoracic cavities and are clinically considered to have a form of heterotaxy syndrome.

Heterotaxy syndrome with atrial isomerism occurs in 1 out of every 10,000 live births and is associated with approximately 3% of congenital heart disease cases.[3] Additional estimation of incidence and prevalence of isomerism proves difficult due to failure to diagnose and underestimation of the disease by clinicians. Furthermore, right isomerism is much more easily recognized than left isomerism, contributing to the failure to diagnose.[4]

Situs ambiguus is a growing field of research with findings dating back to 1973.[5]

Signs and symptomsEdit

There are a variety of clinical manifestations of situs ambiguus. Acute symptoms can be due to both cardiac and non-cardiac defects. Cyanosis or blue skin coloration, primarily affecting the lips and fingernails, can indicate a systemic or circulatory issue. Poor feeding, failure to thrive, and rapid shallow breathing may also be observed due to poor circulation. Upon examination, arrhythmia and heart murmur may raise further suspicion of a cardiac abnormality. Non-cardiac symptoms include impairments of the liver and gastrointestinal tract. Biliary atresia, or inflammation and destruction of the bile ducts, may lead to jaundice. Vomiting and swelling of the abdominal region are features that suggest improper positioning of the intestines. Poor positioning of the intestine also makes it more prone to blockage, which can result in numerous chronic health issues.[4] Asplenia and polysplenia are also possible features of heterotaxy syndrome.[6]

Due to abnormal cardiac development, patients with situs ambiguus usually develop right atrial isomerism consisting of two bilaterally paired right atria, or left atrial isomerism consisting of two bilaterally paired left atria. Clinical features and symptoms can vary dependent upon assignment of left versus right atrial isomerism. In either instance, the apex of the heart will be poorly positioned, which should alert a clinician of the likelihood of atrial isomerism. It is estimated that 5-10% of isomeric patients have mesocardia, in which the heart is positioned at the center of the thorax, 25-50% have dextrocardia, in which the apex of the heart is pointed toward the right side of the thorax, and 50 - 70% have levocardia, in which the apex of the heart is pointed toward the left side of the thorax.[2]

Right atrial appendage isomerismEdit

Right atrial appendage isomerism, also called right atrial isomerism, is a cardiac development defect in which the heart has bilateral right atria and atrial attachments in the muscle wall, as opposed to the normal right atrium and left atrium. In right atrial isomerism, the pulmonary blood oxygen tract is damaged due to right-left shunting of blood. In addition, the atrial septum which distinguishes the 2 atria is absent. These impairments, in addition to congestion in the pulmonary tract, allows deoxygenated blood to mix with oxygenated blood, contributing to cyanosis and possible respiratory distress. Poor systemic circulation also results due to improper positioning of the aorta.[2]

Left atrial appendage isomerismEdit

Left atrial appendage isomerism, also called left atrial isomerism, is a cardiac development defect in which the heart has 2 bilateral left atria and atrial appendages in the muscle wall. Left atrial isomerism can have varied clinical manifestations, including a later onset of symptoms. Heart failure is often a concern because the inferior vena cava is disrupted due to the inappropriate morphology of the left ventricle to support the vena cava.[2]

Conductive nodes and tissuesEdit

Abnormal development of the heart results in impaired doubles of conductive nodes, as well as faulty electrical fibers throughout the ventricles. Individuals with right atrial isomerism develop 2 sinoatrial nodes, as they have 2 mirrored right atria, whereas those with left atrial isomerism fail to develop a sinus node at all. Thus, patients with left atrial isomerism are more likely to experience atrial fibrillation, or irregular rapid heart beat, and abnormal heart rhythm, known as atrial flutter. Development of the atrioventricular node and bundle of His largely depends on physiological looping of the ventricles. Abnormal looping of the ventricles contributes to arrhythmia and heart block in fetuses.[2]

Bronchial tree and lungsEdit

Isomerism of the bronchial tree is not typically damaging and presents no significant clinical complications.[7] Pulmonary valve stenosis results in issues of blood flow to the lungs.

Abdominal organsEdit

Abdominal organs, including the liver, stomach, intestinal tract, and spleen may be randomly arranged throughout the left-right axis of the body. Distribution of these organs largely dictates treatment, clinical outcomes, and further evaluation.

The liver is typically symmetrical across the left-right axis in patients with situs ambiguus, which is abnormal. A majority of left atrial isomeric patients have defects throughout the biliary tree, which is responsible for bile production, even when the gall bladder is functional and morphologically normal. This biliary atresia can lead to acute problems such as nutrient malabsorption, pale stools, dark urine, and abdominal swelling. If this condition continues without proper treatment, cirrhosis and liver failure become a major concern. Biliary atresia is not usually observed in patients with right atrial isomerism.[2]

Random positioning of the stomach is often one of the first signals of situs ambiguus upon examination. Malrotation of the entire intestinal tract, or improper folding and bulging of the stomach and intestines, results in bowel obstruction. This impairment leads to vomiting, abdominal distention, mucus and blood in the stool. Patients may also experience abdominal pain. Intestinal malrotation is more commonly identified in patients with right atrial isomerism than in those with left atrial isomerism.[citation needed]

Isomeric patients often experience disruptions to splenic development during embryogenesis, resulting in an overall lack a spleen (asplenia) or development of many spleens (polysplenia). Asplenia is most often observed in patients with right atrial isomerism. Polysplenia results in 90% of patients with left atrial isomerism. Although they have many spleens, each is usually ineffective resulting in functional asplenia. Rarely, left atrial isomeric patients have a single, normal, functional spleen. Patients lacking a functional spleen are in danger of sepsis and must be monitored.[2]


Although its cause is poorly understood, situs ambiguus has been linked to family history of malformations[8][9] and maternal cocaine use,[10] suggesting both genetic and environmental factors play a role.[11] Several genes in the TGF-beta pathway, which controls left-right patterning of visceral organs across the body axis, have been indicated in sporadic and familial cases of atrial isomerism. Disrupted mitochondria function has also been recently linked to heterotaxy. [12]


Molecular and cellular mechanismEdit

Several genes have been identified in normal development of the right-left axis.[13] These genes have been extensively researched. Gene mutations that lead to atrial isomerism is a growing area of research. Mutations in genes that encode proteins in the TGF-beta pathway, including NODAL, NKX2-5, and ZIC3, have been linked to tetralogy of fallot and hypoplastic left heart syndrome.[14][15] Mutations in the ZIC3 gene, which encodes for the first zinc finger transcription factor, is linked to a 50% risk of atrial isomerism in families. It is also an X-linked disorder, so testing for ZIC3 mutations is highly encouraged in male births.[16]

The most prevalent and best characterized genetic associations of heterotaxy include:[2]

Type OMIM Gene Locus
HTX1 306955 ZIC3 Xq26.2
HTX2 605376 CFC1 2q21.1
HTX3 606325 PA26 6q21
HTX4 613751 ACVR2B 992
HTX5 270100 NODAL 10q22.1
HTX6 614779 CCDC11 18q21.1

Classical pathologyEdit

Bronchial tree and lungsEdit

Pathophysiology in the bronchial tree can be observed by radiography. Under normal development, the bronchial tree consists of two main bronchi that are anatomically different:

  • Hyparterial bronchus (below the pulmonary artery): supplies blood to the bi-lobed left lung
  • Eparterial bronchus (adjacent to the artery): supplies blood to the tri-lobed right lung

In situs ambiguus, there is a duplication of either the hyparterial or eparterial bronchus. These features are not associated with any significant clinical complications.[17] Mechanisms leading to bronchial duplication are not thoroughly understood.

In pulmonary valve stenosis, there is a reduction in blood flow to the lungs due to an obstruction of the heart at the pulmonic valve. This contributes to cyanosis and pulmonary hypertension.[18]


For proper diagnosis of situs ambiguus, cardiac and non-cardiac features must be evaluated. Diagnostic criteria for atrial isomerism includes observation of symmetry of thoracic visceral organs upon echocardiogram, arrhythmia upon electrocardiogram, and chest x-ray for confirmation of the heart's location across the left-right axis. In addition, a series of gastrointestinal tests can be conducted for observation of intestinal malrotation, as well as a scan of the liver and spleen for biliary function.[2]

Diagnostic techniques for cardiac causesEdit

Diagnostic techniques for non-cardiac causesEdit

Other diagnostic featuresEdit


Each of the symptoms of situs ambiguus must be managed with appropriate treatment dependent upon the organ system involved. Intestinal malrotation is treated surgically using the Ladd procedure. This procedure widens a fold in the peritoneum so that the intestines can be placed in non-rotated formation. It is not possible to return the bowel to a normal morphology[19] However, 89% of patients that undergo the Ladd surgery experience a complete resolution of symptoms.

Following cholangiogram, a Kasai procedure is usually performed in cases of biliary atresia. In this surgery, a Y-shaped shunt is used to passage bile from the liver directly to the intestine. If this is unsuccessful, liver transplantation can be considered based on the overall health of the patient. The Kasai procedure is successful in approximately 80% of patients.[20] Following the operation, patients are advised to take fat-soluble vitamins, choleretics, and anti-inflammatory medications.

Functionally asplenic patients have an elevated lifetime risk of sepsis, as they have no functional spleen for fighting infection. For this reason, asplenic patients are under constant observation for any signs of fever or infection. In the case of infection, patients are placed on controlled empiric antibiotic therapy to avoid development of antibiotic resistance.[21] This therapy battles infection by both gram-positive and gram-negative bacteria.

Right-atrial and left-atrial isomerism and associated pulmonary issues are treated in a series of steps based on the severity of symptoms. Isomeric patients are first treated by inserting a shunt that will move incoming blood through the pulmonary circuit. The Fontan procedure routes blood through the patient's single ventricle, to the lungs, and into systemic circulation. This process is favorable in patients aged 2 to 5 years old. About 20-30% of patients will require a heart transplant.[22] Left-atrial isomeric patients have less severe complications, as they typically have 2 functional ventricles. In this case, they can undergo biventricular repair to form 2 separate ventricles and functional associated valves.


Prognosis for patients with situs ambiguus is quite varied, considering the spectrum of clinical complications. Infants who experience severe cyanosis at birth die within hours of delivery if medical intervention is not immediate. Alternatively, longevity of neonates with mild cardiac lesions is unaffected.[23] Ten percent of patients born with right atrial isomerism die by the age of 5 without intervention. Improvements in therapies has increased the 5-year survival to 30-74% for right atrial isomeric patients and 65-84% for left atrial isomeric patients based on the cause of their disease.


There have been vast amounts of research on the clinical features, racial disparities, and physiological mechanisms of heterotaxy syndrome dating back to 1973.

Mishra et al. published a review in November 2015 describing current knowledge of cardiac and non-cardiac abnormalities associated with situs ambiguus. The author stresses the importance of genetic testing prior to deciding a prognosis for affected patients.[24] She also proposes prenatal screening and evaluation in cases at risk for development of situs ambiguus.

Recent studies have shown higher rates of heterotaxy syndrome among Hispanic infants of Mexican descent, as well as female infants of non-Hispanic black and white mothers. Additional studies must be done to clarify the mechanisms behind racial disparities in heterotaxy syndrome.[25] Individuals of Asian descent show a higher prevalence of heterotaxy syndrome in general than members of the Western world.[26]

The National Birth Defects Prevention study (October 2014) attempted to link clinical presentations of situs ambiguus to demographics in an epidemiological study.[27] This proved a difficult task due to the vast differences in presentation of this disorder. However, the authors are hopeful that finding a link can help inform clinical decision-making, predictive analyses, and future outcomes.

See alsoEdit


  1. ^ "heterotaxy syndrome". United States National Library of Medicine. Retrieved 23 May 2016.
  2. ^ a b c d e f g h i Lowenthal, A.; et al. (September 26, 2015). "Anatomy, clinical manifestations and diagnosis of heterotaxy (isomerism of the atrial appendages)". Up To Date. Retrieved November 4, 2015.
  3. ^ Zhu, Lirong; Belmont, John W.; Ware, Stephanie M. (2005-10-26). "Genetics of human heterotaxias". European Journal of Human Genetics. 14 (1): 17–25. doi:10.1038/sj.ejhg.5201506. ISSN 1018-4813. PMID 16251896.
  4. ^ a b Kim, Soo-Jin (2011). "Heterotaxy Syndrome". Korean Circulation Journal. 41 (5): 227–32. doi:10.4070/kcj.2011.41.5.227. PMC 3116098. PMID 21731561.
  5. ^ Freedom, Robert M.; Treves, S. (1973-05-01). "Splenic Scintigraphy and Radionuclide Venography in the Heterotaxy Syndrome". Radiology. 107 (2): 381–386. doi:10.1148/107.2.381. ISSN 0033-8419. PMID 4695908.
  6. ^ Van Praagh, R; et al. (December 15, 1990). "Atrial isomerism in the heterotaxy syndromes with asplenia, or polysplenia, or normally formed spleen: an erroneous concept". Am J Cardiol. 66 (20): 1504–6. doi:10.1016/0002-9149(90)90543-a. PMID 2252000.
  7. ^ Cohen, Meryl S.; Anderson, Robert H.; Cohen, Mitchell I.; Atz, Andrew M.; Fogel, Mark; Gruber, Peter J.; Lopez, Leo; Rome, Jonathan J.; Weinberg, Paul M. (2007). "Controversies, genetics, diagnostic assessment, and outcomes relating to the heterotaxy syndrome". Cardiology in the Young. 17 (S2): 29–43. doi:10.1017/s104795110700114x. PMID 18039397.
  8. ^ Martínez-Frías ML (March 2001). "Heterotaxia as an outcome of maternal diabetes: an epidemiological study". American Journal of Medical Genetics. 99 (2): 142–6. doi:10.1002/1096-8628(2000)9999:999<00::AID-AJMG1139>3.0.CO;2-Z. PMID 11241474.
  9. ^ Maeyama K, Kosaki R, Yoshihashi H, Casey B, Kosaki K (March 2001). "Mutation analysis of left-right axis determining genes in NOD and ICR, strains susceptible to maternal diabetes". Teratology. 63 (3): 119–26. doi:10.1002/tera.1022. PMID 11283968.
  10. ^ Kuehl KS, Loffredo C (November 2002). "Risk factors for heart disease associated with abnormal sidedness". Teratology. 66 (5): 242–8. doi:10.1002/tera.10099. PMID 12397632.
  11. ^ Kuehl KS, Loffredo CA (March 2003). "Population-based study of l-transposition of the great arteries: possible associations with environmental factors". Birth Defects Research. Part A, Clinical and Molecular Teratology. 67 (3): 162–7. doi:10.1002/bdra.10015. PMID 12797457.
  12. ^ Burkhalter MD, Sridhar A, Sampaio P, Jacinto R, Burczyk MS, Donow C, Angenendt M, Competence Network for Congenital Heart Defects Investigators, Hempel M, Walther P, Pennekamp P, Omran H, Lopes SS, Ware SM, Philipp M (2019). "Imbalanced mitochondrial function provokes heterotaxy via aberrant ciliogenesis". J Clin Invest. 129 (7): 2841–2855. doi:10.1172/JCI98890. PMC 6597216. PMID 31094706.CS1 maint: multiple names: authors list (link)
  13. ^ Chen, CM; et al. (April 2010). "Transcriptional Control of Left–Right Patterning in Cardiac Development". Pediatric Cardiology. 31 (3): 371–377. doi:10.1007/s00246-009-9610-3. PMID 20054532. S2CID 300003.
  14. ^ Kosaki, K; Bassi, M T; Kosaki, R; Lewin, M; Belmont, J; Schauer, G; Casey, B (1999-03-01). "Characterization and mutation analysis of human LEFTY A and LEFTY B, homologues of murine genes implicated in left-right axis development". American Journal of Human Genetics. 64 (3): 712–721. doi:10.1086/302289. ISSN 0002-9297. PMC 1377788. PMID 10053005.
  15. ^ Mohapatra, Bhagyalaxmi; Casey, Brett; Li, Hua; Ho-Dawson, Trang; Smith, Liana; Fernbach, Susan D.; Molinari, Laura; Niesh, Stephen R.; Jefferies, John Lynn (2009-03-01). "Identification and functional characterization of NODAL rare variants in heterotaxy and isolated cardiovascular malformations". Human Molecular Genetics. 18 (5): 861–871. doi:10.1093/hmg/ddn411. ISSN 1460-2083. PMC 2722226. PMID 19064609.
  16. ^ Gebbia, Marinella; Ferrero, Giovanni B.; Pilia, Giuseppe; Bassi, Maria T.; Aylsworth, Arthur S.; Penman-Splitt, Miranda; Bird, Lynne M.; Bamforth, John S.; Burn, John (1997-11-01). "X-linked situs abnormalities result from mutations in ZIC3". Nature Genetics. 17 (3): 305–308. doi:10.1038/ng1197-305. PMID 9354794. S2CID 22916101.
  17. ^ Applegate, Kimberly E.; Goske, Marilyn J.; Pierce, Gregory; Murphy, Daniel (1999-07-01). "Situs Revisited: Imaging of the Heterotaxy Syndrome". RadioGraphics. 19 (4): 837–852. doi:10.1148/radiographics.19.4.g99jl31837. ISSN 0271-5333. PMID 10464794.
  18. ^ Lowenthal, Alexander; et al. (October 27, 2015). "Management and outcome of heterotaxy (isomerism of the atrial appendages)". UpToDate. Retrieved December 8, 2015.
  19. ^ Brandt, Mary; et al. (October 24, 2015). "Intestinal Malrotation". UpToDate. Retrieved December 10, 2015.
  20. ^ Erlichman, Jessi; et al. (August 3, 2015). "Biliary Atresia". UpToDate. Retrieved December 9, 2015.
  21. ^ Pasternack, Mark S; et al. (December 11, 2014). "Clinical features and management of sepsis in the asplenic patient". UpToDate. Retrieved December 10, 2015.
  22. ^ Anderson PA, Sleeper LA, Mahony L, et al. (2008). ""Contemporary outcomes after the Fontan procedure: A Pediatric Heart Network multicenter study."". Journal of the American College of Cardiology. 52 (2): 85–93. doi:10.1016/j.jacc.2008.01.074. PMC 4385517. PMID 18598886.
  23. ^ Hashmi, Aijaz; Abu-Sulaiman, Riyadh; McCrindle, Brian W; Smallhorn, Jeffrey F; Williams, William G; Freedom, Robert M (1998-04-01). "Management and Outcomes of Right Atrial Isomerism: A 26-Year Experience". Journal of the American College of Cardiology. 31 (5): 1120–1126. doi:10.1016/S0735-1097(98)00062-X. PMID 9562017.
  24. ^ Mishra, Smita (2015-11-26). "Cardiac and Non-Cardiac Abnormalities in Heterotaxy Syndrome". The Indian Journal of Pediatrics. 82 (12): 1135–1146. doi:10.1007/s12098-015-1925-x. ISSN 0019-5456. PMID 26612104. S2CID 207388492.
  25. ^ Lopez, Keila N.; Marengo, Lisa K.; Canfield, Mark A.; Belmont, John W.; Dickerson, Heather A. (2015-09-01). "Racial disparities in heterotaxy syndrome". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (11): 941–950. doi:10.1002/bdra.23416. ISSN 1542-0760. PMID 26333177.
  26. ^ Kim, Soo-Jin; Kim, Woong-Han; Lim, Hong-Gook; Lee, Jae-Young (July 2008). "Outcome of 200 patients after an extracardiac Fontan procedure". The Journal of Thoracic and Cardiovascular Surgery. 136 (1): 108–116. doi:10.1016/j.jtcvs.2007.12.032. hdl:10371/60103. PMID 18603062.
  27. ^ Lin, Angela E.; Krikov, Sergey; Riehle-Colarusso, Tiffany; Frías, Jaime L.; Belmont, John; Anderka, Marlene; Geva, Tal; Getz, Kelly D.; Botto, Lorenzo D. (2014-10-01). "Laterality defects in the national birth defects prevention study (1998–2007): Birth prevalence and descriptive epidemiology". American Journal of Medical Genetics Part A. 164 (10): 2581–2591. doi:10.1002/ajmg.a.36695. ISSN 1552-4833. PMC 4462240. PMID 25099286.

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