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Anomalous left anterior descending coronary artery in a pediatric patient with Fallot tetralogy
Journal of Cardiovascular Computed Tomography (2008) 2, 55–56
Images in Cardiovascular CT
Anomalous left anterior descending coronary artery in a pediatric patient with Fallot tetralogy Stephan Achenbach, MDa*, Sven Dittrich, MDb, Axel Kuettner, MDc Departments of aCardiology, bPediatric Cardiology, and cRadiology, University of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany KEYWORDS: Anomalies; Computed tomography; Fallot tetralogy
Cardiac CT was performed in a 3-year-old patient (weight, 12.4 kg; heart rate, 100 beats/minute) with tetralogy of Fallot (pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy) to rule out coronary anomalies before surgical correction. A shunt graft from the brachiocephalic trunk to the pulmonary artery had been placed in the patient at the age of 8 months. Data were acquired in free breathing using dual-source CT (DSCT). Fifteen milliliters of contrast agent (2 mL/second) was injected, followed by 20 mL of saline chaser. Tube voltage was 100 kV. Maximum tube current was 300 mAs (30%– 80% of the cardiac cycle). Transaxial images were reconstructed with 0.6-mm slice thickness and 0.3-mm increment (36% of R-R interval). DSCT showed clockwise rotation of the aortic root with an anteriorly displaced right coronary ostium. The left anterior descending coronary artery originated from the right coronary ostium and coursed anterior to the right ventricular outflow tract (RVOT) (Figs. 1, 2, and 3). The left main stem
Conflict of interest: Dr. Achenbach and Dr. Kuettner have received research grants from Siemens, Bracco, and Schering and speaker honoraria from Siemens and Bracco. Dr. Dittrich reports no conflict. * Corresponding author. E-mail address: [email protected] The online version of this article contains supplementary data. Submitted November 3, 2007. Accepted for publication December 5, 2007.
divided into a small septal branch (Fig. 4) and the left circumflex artery. In addition, a left persistent superior vena cava with typical drainage into the coronary sinus was found (see Fig. 1). The movie shows a cine display of the typical ventricular septal defect with an overriding aorta (Movie Supplement 1, see supplementary material online at www.CardiacCTJournal.com). Coronary anomalies occur in up to 10% of patients with tetralogy of Fallot.1,2 Often, a left main or left anterior descending coronary artery will arise from the right sinus of Valsalva and cross the RVOT, which may require modifying the surgical approach for RVOT enlargement.
References 1. Özkara A, Mert M, Cetin G, Saltik L, Sarioglu T. Right ventricular outflow tract reconstruction for Tetralogy of Fallot with abnormal coronary artery: experience with 35 patients. J Card Surg. 2006;21:131– 6. 2. Burch GH, Sahn DJ. Congenital coronary artery anomalies: the pediatric perspective. Coron Artery Dis. 2001;12:605–16.
Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jcct.2007.12.005.
1934-5925/$ -see front matter © 2008 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2007.12.005
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Journal of Cardiovascular Computed Tomography, Vol 2, No 1, January/February 2008
Figure 1 Two-dimensional maximum intensity projection (5-mm thickness) in transaxial orientation. The left anterior descending coronary artery can be seen to arise from a right coronary artery ostium that has an anterior position. The left anterior descending coronary artery crosses the right ventricular outflow tract (arrows). An arrowhead indicates a small side branch also extending across the right ventricular outflow tract. The asterisk denotes a left persistent superior vena cava.
Figure 2 Two-dimensional multiplanar reconstruction (5-mm thick maximum intensity projection) along the right ventricular outflow tract. A cross-section of the anomalous left anterior descending coronary artery is seen (large arrow); approximately 2 mm of myocardium is between the vessel and the right ventricular outflow tract. The arrowheads point at the shunt that had been placed between the brachiocephalic trunk and the pulmonary artery. The small arrow points at the pulmonary stenosis.
Figure 3 Three-dimensional reconstruction, volume-rendering technique seen from an anterior position. The anomalous left anterior descending coronary artery can be seen to course over the right ventricular outflow tract (arrows). The arrowheads point at the subclavian-to-pulmonary artery shunt.
Figure 4 Two-dimensional maximum intensity projection (5-mm thickness) showing a small septal branch (small arrows) arising from the left main coronary artery (large arrow). Because of the clockwise rotation of the aortic root, the ostium of the left main coronary artery is displaced posteriorly.
Images in Cardiovascular CT
Anomalous left anterior descending coronary artery in a pediatric patient with Fallot tetralogy Stephan Achenbach, MDa*, Sven Dittrich, MDb, Axel Kuettner, MDc Departments of aCardiology, bPediatric Cardiology, and cRadiology, University of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany KEYWORDS: Anomalies; Computed tomography; Fallot tetralogy
Cardiac CT was performed in a 3-year-old patient (weight, 12.4 kg; heart rate, 100 beats/minute) with tetralogy of Fallot (pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy) to rule out coronary anomalies before surgical correction. A shunt graft from the brachiocephalic trunk to the pulmonary artery had been placed in the patient at the age of 8 months. Data were acquired in free breathing using dual-source CT (DSCT). Fifteen milliliters of contrast agent (2 mL/second) was injected, followed by 20 mL of saline chaser. Tube voltage was 100 kV. Maximum tube current was 300 mAs (30%– 80% of the cardiac cycle). Transaxial images were reconstructed with 0.6-mm slice thickness and 0.3-mm increment (36% of R-R interval). DSCT showed clockwise rotation of the aortic root with an anteriorly displaced right coronary ostium. The left anterior descending coronary artery originated from the right coronary ostium and coursed anterior to the right ventricular outflow tract (RVOT) (Figs. 1, 2, and 3). The left main stem
Conflict of interest: Dr. Achenbach and Dr. Kuettner have received research grants from Siemens, Bracco, and Schering and speaker honoraria from Siemens and Bracco. Dr. Dittrich reports no conflict. * Corresponding author. E-mail address: [email protected] The online version of this article contains supplementary data. Submitted November 3, 2007. Accepted for publication December 5, 2007.
divided into a small septal branch (Fig. 4) and the left circumflex artery. In addition, a left persistent superior vena cava with typical drainage into the coronary sinus was found (see Fig. 1). The movie shows a cine display of the typical ventricular septal defect with an overriding aorta (Movie Supplement 1, see supplementary material online at www.CardiacCTJournal.com). Coronary anomalies occur in up to 10% of patients with tetralogy of Fallot.1,2 Often, a left main or left anterior descending coronary artery will arise from the right sinus of Valsalva and cross the RVOT, which may require modifying the surgical approach for RVOT enlargement.
References 1. Özkara A, Mert M, Cetin G, Saltik L, Sarioglu T. Right ventricular outflow tract reconstruction for Tetralogy of Fallot with abnormal coronary artery: experience with 35 patients. J Card Surg. 2006;21:131– 6. 2. Burch GH, Sahn DJ. Congenital coronary artery anomalies: the pediatric perspective. Coron Artery Dis. 2001;12:605–16.
Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jcct.2007.12.005.
1934-5925/$ -see front matter © 2008 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2007.12.005
56
Journal of Cardiovascular Computed Tomography, Vol 2, No 1, January/February 2008
Figure 1 Two-dimensional maximum intensity projection (5-mm thickness) in transaxial orientation. The left anterior descending coronary artery can be seen to arise from a right coronary artery ostium that has an anterior position. The left anterior descending coronary artery crosses the right ventricular outflow tract (arrows). An arrowhead indicates a small side branch also extending across the right ventricular outflow tract. The asterisk denotes a left persistent superior vena cava.
Figure 2 Two-dimensional multiplanar reconstruction (5-mm thick maximum intensity projection) along the right ventricular outflow tract. A cross-section of the anomalous left anterior descending coronary artery is seen (large arrow); approximately 2 mm of myocardium is between the vessel and the right ventricular outflow tract. The arrowheads point at the shunt that had been placed between the brachiocephalic trunk and the pulmonary artery. The small arrow points at the pulmonary stenosis.
Figure 3 Three-dimensional reconstruction, volume-rendering technique seen from an anterior position. The anomalous left anterior descending coronary artery can be seen to course over the right ventricular outflow tract (arrows). The arrowheads point at the subclavian-to-pulmonary artery shunt.
Figure 4 Two-dimensional maximum intensity projection (5-mm thickness) showing a small septal branch (small arrows) arising from the left main coronary artery (large arrow). Because of the clockwise rotation of the aortic root, the ostium of the left main coronary artery is displaced posteriorly.