Capabilities of Computed Tomographic Angiography: A Case of Anomalous Origin of the Right Subclavian and Left Pulmonary Arteries in an Infant With Tetralogy of Fallot

Objective: To demonstrate capabilities of multislice computed tomography (CT) in detailing a congenital heart disease (CHD), tetralogy of Fallot (TOF), in an infant.

Case report: We report a case of suspected TOF in a 3-month-old patient who underwent transthoracic echocardiography (TTE) at an initial hospitalization site and was admitted to the Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation) for further examination and treatment planning. The examination was supplemented with CT and computed tomographic angiography (CTA).

Results: TTE diagnosed TOF, patent ductus arteriosus, functional foramen ovale, right-sided aortic arch, and major aortopulmonary collateral arteries. CT and CTA revealed biventricular origin of the aorta, infundibular pulmonary stenosis, right ventricular outflow tract stenosis, and abnormal origin of the left pulmonary artery and the right subclavian artery.

Discussion: TTE is the primary screening method for TOF; however, its data are insufficient for planning surgical treatment. As a clarifying method, CTA is needed to detail the CHD, objectively assess the aorta, pulmonary veins and arteries, and exclude an extracardiac pathology.

Conclusions: The success of CHD surgical correction in children lies in the preoperative assessment of all anatomical features that determine the sequence of treatment and potential surgical risks. Using a single imaging method is insufficient to obtain reliable and accurate results when choosing a surgical strategy for patients with complex CHDs. Chest CTA has proven to be a highly effective method in assessing the CHD and clinically significant anatomical features.

1. Podzolkov VN, Shvedunova VN. Congenital heart diseases. RMJ. 2001;(10):430. (In Russ.).

2. Shatalov KV, Dzhidzhikhiya KM. The influence of truncal rotation on the type of congenital heart defect. Part 1. Double-outlet right ventricle. Children’s Heart and Vascular Diseases. 2021;18(3):168–175. (In Russ.).

3. Russian Association of Cardio-Vascular Surgeons, Association of Russian Paediatric Cardiologists, Russian Society of Cardiology, Russian Scientific Society of Endovascular Therapies, National Spa Association. Clinical Guidelines. Tetralogy of Fallot. Ministry of Health of the Russian Federation; 2021. (In Russ.).

4. Luetmer PH, Miller GM. Right aortic arch with isolation of the left subclavian artery: case report and review of the literature. Mayo Clin Proc. 1990;65(3):407–413. PMID: 2179646. https://doi.org/10.1016/s0025-6196(12)62540-3

5. Edwards JE. Anomalies of the derivatives of the aortic arch system. Med Clin North Am. 1948;32:925–949. PMID: 18877614. https://doi.org/10.1016/s0025-7125(16)35662-0

6. Lee Y, Hong SW. Abnormal origin of the left subclavian artery from the left pulmonary artery in a patient with double outlet right ventricle. Korean J Thorac Cardiovasc Surg. 2014;47(1):32–34. PMID: 24570863. PMCID: PMC3928260. https://doi.org/10.5090/kjtcs.2014.47.1.32

7. McMahon CJ, Thompson KS, Kearney DL, Nihill MR. Subclavian steal syndrome in anomalous connection of the left subclavian artery to the pulmonary artery in d-transposition of the great arteries. Pediatr Cardiol. 2001;22(1):60–62. PMID: 11123131. https://doi.org/10.1007/s002460010155

8. Nath PH, Castaneda-Zuniga W, Zollikofer C, et al. Isolation of a subclavian artery. AJR Am J Roentgenol. 1981;137(4):683–688. PMID: 6974961. https://doi.org/10.2214/ajr.137.4.683

9. Gnanappa GK, Laohachai K, Orr Y, Ayer J. Isolated anomalous origin of left pulmonary artery from the descending aorta: an embryologic ambiguity. Ann Thorac Surg. 2016;102(5):e439–e441. PMID: 27772603. https://doi.org/10.1016/j.athoracsur.2016.04.089

10. Ganigara M, Doshi A, Naimi I, Mahadevaiah GP, Buddhe S, Chikkabyrappa SM. Preoperative physiology, imaging, and management of coarctation of aorta in children. Semin Cardiothorac Vasc Anesth. 2019;23(4):379–386. Published correction appears in Semin Cardiothorac Vasc Anesth. 2021;25(1):77. PMID: 31535945. https://doi.org/10.1177/1089253219873004

11. Zhang Y, Yang ZG, Yang MX, et al. Common atrium and the associated malformations: Evaluation by low-dose dual-source computed tomography. Medicine (Baltimore). 2018;97(46):e12983. PMID: 30431572. PMCID: PMC6257481. https://doi.org/10.1097/MD.0000000000012983

12. Liu J, Li H, Liu Z, Wu Q, Xu Y. Complete preoperative evaluation of pulmonary atresia with ventricular septal defect with multi-detector computed tomography. PLoS One. 2016;11(1):e0146380. PMID: 26741649. PMCID: PMC4712153. https://doi.org/10.1371/journal.pone.0146380

13. Garg N, Walia R, Neyaz Z, Kumar S. Computed tomographic versus catheterization angiography in tetralogy of Fallot. Asian Cardiovasc Thorac Ann. 2015;23(2):164–175. PMID: 24912609. https://doi.org/10.1177/0218492314538844

14. Ramirez-Suarez KI, Tierradentro-García LO, Otero HJ, et al. Optimizing neonatal cardiac imaging (magnetic resonance/ computed tomography). Pediatr Radiol. 2022;52(4):661–675. PMID: 34657169. https://doi.org/10.1007/s00247-021-05201-w

15. Masuda T, Funama Y, Nakaura T, et al. Influence of contrast enhancement at the contrast injection location for the arm or leg in neonatal and infant patients during cardiac computed tomography. Radiologia (Engl Ed). 2022;64(6):525–532. PMID: 36402538. https://doi.org/10.1016/j.rxeng.2021.10.001