Case Report Left-Sided Patent Ductus Arteriosus in...
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Case Report Left-Sided Patent Ductus Arteriosus in a Right-Sided Aortic Arch Ming-Yen Ng, 1,2 Paaladinesh Thavendiranathan, 1,3 Andrew Michael Crean, 1,3 Qin Li, 3 and Djeven Parameshvara Deva 4 1 Department of Medical Imaging, Toronto General Hospital, Toronto, ON, Canada M5G 2C4 2 Department of Diagnostic Radiology, e University of Hong Kong, Hong Kong 3 Division of Cardiology, Toronto General Hospital, Toronto, ON, Canada M5G 2C4 4 Department of Medical Imaging, St. Michael’s Hospital, Toronto, ON, Canada M5B 1W8 Correspondence should be addressed to Ming-Yen Ng; [email protected] Received 3 June 2014; Accepted 28 October 2014; Published 17 November 2014 Academic Editor: Salah D. Qanadli Copyright © 2014 Ming-Yen Ng et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We present a 31-year-old female with repaired tetralogy of Fallot (TOF) and right-sided aortic arch (RAA) with leſt-sided patent ductus arteriosus (PDA) originating from the leſt brachiocephalic artery. is is a rare finding but most common site for a PDA in TOF and a RAA. To the best of our knowledge, this is the first demonstration of this rare finding on MRI in the literature. 1. Introduction We present a 31-year-old female with repaired tetralogy of Fallot (TOF) (transannular patch repair of the right ven- tricular outflow tract) and right-sided aortic arch with leſt- sided patent ductus arteriosus (PDA) originating from the leſt brachiocephalic artery, which is a rare finding, but most common site for a PDA in individuals with TOF and a right- sided aortic arch. To the best of our knowledge there are no other cases in the literature demonstrated on MRI. 2. Case Report e patient underwent cardiac magnetic resonance imaging (MRI) as part of investigations prior to pregnancy but was otherwise asymptomatic. MRI demonstrated a right-sided aortic arch with mirror image branching and a tubular structure connecting the leſt brachiocephalic artery to the distal pulmonary trunk (see Figure 1). e magnetic reso- nance angiogram (MRA) demonstrated blood flow through the tubular structure but the pulmonary-systemic stroke volume ratio (Qp : Qs ratio) was 1 : 1. erefore, there was no significant shunt and no intervention was required. Previous imaging was done in a different institution more than twenty years previously and was not available for comparison. e differential diagnosis for this appearance was a modified Blalock-Taussig shunt but this was ruled out based on surgical notes. e PDA position is consistent with Edward’s developmental model of the aortic arch. 3. Discussion In Edward’s developmental model of the aortic arch the development of the right-sided aortic arch with mirror image branching occurs due to involution of the dorsal segment of the leſt arch between the leſt subclavian artery and descend- ing aorta [1–3]. e right ductus arteriosus also undergoes involution and the remaining leſt ductus arteriosus usually originates from the leſt brachiocephalic artery or subclavian artery. is configuration may form a vascular ring with associated symptoms of dysphagia (though this was not the case in our patient). While this is the most common anatomical arrangement in tetralogy of Fallot with a right aortic arch, it is still an extremely rare observation in adult clinical practice. Other documented positions of the PDA in patients with tetralogy of Fallot include origins from an aberrant leſt subclavian artery in a right aortic arch, from a diverticulum which also gives off the aberrant leſt subclavian artery, and from the leſt common carotid artery in the context of aberrant leſt subclavian artery, and, rarely, there can be a right PDA Hindawi Publishing Corporation Case Reports in Radiology Volume 2014, Article ID 896071, 3 pages http://dx.doi.org/10.1155/2014/896071
Transcript of Case Report Left-Sided Patent Ductus Arteriosus in...
Case ReportLeft-Sided Patent Ductus Arteriosus in a Right-Sided Aortic Arch
Ming-Yen Ng,1,2 Paaladinesh Thavendiranathan,1,3 Andrew Michael Crean,1,3
Qin Li,3 and Djeven Parameshvara Deva4
1 Department of Medical Imaging, Toronto General Hospital, Toronto, ON, Canada M5G 2C42Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong3Division of Cardiology, Toronto General Hospital, Toronto, ON, Canada M5G 2C44Department of Medical Imaging, St. Michael’s Hospital, Toronto, ON, Canada M5B 1W8
Correspondence should be addressed to Ming-Yen Ng; [email protected]
Received 3 June 2014; Accepted 28 October 2014; Published 17 November 2014
Academic Editor: Salah D. Qanadli
Copyright © 2014 Ming-Yen Ng et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We present a 31-year-old female with repaired tetralogy of Fallot (TOF) and right-sided aortic arch (RAA) with left-sided patentductus arteriosus (PDA) originating from the left brachiocephalic artery. This is a rare finding but most common site for a PDA inTOF and a RAA. To the best of our knowledge, this is the first demonstration of this rare finding on MRI in the literature.
1. Introduction
We present a 31-year-old female with repaired tetralogy ofFallot (TOF) (transannular patch repair of the right ven-tricular outflow tract) and right-sided aortic arch with left-sided patent ductus arteriosus (PDA) originating from theleft brachiocephalic artery, which is a rare finding, but mostcommon site for a PDA in individuals with TOF and a right-sided aortic arch. To the best of our knowledge there are noother cases in the literature demonstrated on MRI.
2. Case Report
The patient underwent cardiac magnetic resonance imaging(MRI) as part of investigations prior to pregnancy but wasotherwise asymptomatic. MRI demonstrated a right-sidedaortic arch with mirror image branching and a tubularstructure connecting the left brachiocephalic artery to thedistal pulmonary trunk (see Figure 1). The magnetic reso-nance angiogram (MRA) demonstrated blood flow throughthe tubular structure but the pulmonary-systemic strokevolume ratio (Qp :Qs ratio) was 1 : 1. Therefore, there was nosignificant shunt and no intervention was required. Previousimaging was done in a different institution more than twentyyears previously and was not available for comparison. Thedifferential diagnosis for this appearance was a modified
Blalock-Taussig shunt but this was ruled out based onsurgical notes. The PDA position is consistent with Edward’sdevelopmental model of the aortic arch.
3. Discussion
In Edward’s developmental model of the aortic arch thedevelopment of the right-sided aortic arch withmirror imagebranching occurs due to involution of the dorsal segment ofthe left arch between the left subclavian artery and descend-ing aorta [1–3]. The right ductus arteriosus also undergoesinvolution and the remaining left ductus arteriosus usuallyoriginates from the left brachiocephalic artery or subclavianartery. This configuration may form a vascular ring withassociated symptoms of dysphagia (though this was notthe case in our patient). While this is the most commonanatomical arrangement in tetralogy of Fallot with a rightaortic arch, it is still an extremely rare observation in adultclinical practice.
Other documented positions of the PDA in patientswith tetralogy of Fallot include origins from an aberrant leftsubclavian artery in a right aortic arch, from a diverticulumwhich also gives off the aberrant left subclavian artery, andfrom the left common carotid artery in the context of aberrantleft subclavian artery, and, rarely, there can be a right PDA
Hindawi Publishing CorporationCase Reports in RadiologyVolume 2014, Article ID 896071, 3 pageshttp://dx.doi.org/10.1155/2014/896071
2 Case Reports in Radiology
Tr
∗
(a) (b)
Ao
(c)
Tr
SVC
(d) (e)
MPA
LPA
(f)
MPALPA
Ao
∗
(g)
LPAMPA
RPA
SVC
RA RV
(h)
LPAAo
∗
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Figure 1: Axial half-Fourier acquisition single shot turbo spin echo images (images (a)–(f)) show the PDA (white arrow) coming off theleft brachiocephalic artery and draining into the distal pulmonary trunk. 3D volume-rendered image (image (g), see Supplementary Video1 in Supplementary Material available online at http://dx.doi.org/10.1155/2014/896071) demonstrating the PDA originating from the leftbrachiocephalic artery and draining into the distal pulmonary trunk. Maximum intensity projection of the time-resolved MRA (images(h) and (i), Supplementary Video 2), the PDA is not visible during the pulmonary arterial phase (h) but fills once contrast enters the rightsided aortic arch during the systemic arterial phase ((i), arrow). Ao: aorta, ∗: left brachiocephalic artery, LPA: left pulmonary artery, RPA:right pulmonary artery, SVC: superior vena cava, Tr: trachea, MPA: main pulmonary artery, RA: right atrium, and RV: right ventricle.
Case Reports in Radiology 3
connected to the right pulmonary artery. The PDA can arisefrom the right subclavian artery in a left aortic arch or froma diverticulum when in conjunction with an aberrant rightsubclavian [4].
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper.
References
[1] J. Edwards, “Anomalies of the derivatives of the aortic archsystem,”Medical Clinics of North America, vol. 32, pp. 925–949,1948.
[2] L. Ramos-Duran, J. W. Nance Jr., U. J. Schoepf, T. Henzler,P. Apfaltrer, and A. M. Hlavacek, “Developmental aortic archanomalies in infants and children assessed with CT angiog-raphy,” American Journal of Roentgenology, vol. 198, no. 5, pp.W466–W474, 2012.
[3] A. Turkvatan, F. G. Buyukbayraktar, T. Olcer, and T. Cumhur,“Congenital anomalies of the aortic arch: evaluation with theuse of multidetector computed tomography,” Korean Journal ofRadiology, vol. 10, no. 2, pp. 176–184, 2009.
[4] J. W. Kirklin and N. T. Kouchoukos, Kirklin/Barratt-BoyesCardiac Surgery: Morphology, Diagnostic Criteria, Natural His-tory, Techniques, Results, and Indications, Churchill Livingstone,Philadelphia, Pa, USA, 3rd edition, 2003.
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