Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients commonly undergo a Cardiac CT as an imperative pre-operative investigation for detailed information of these collaterals which helps plan further management. Here, we present a Case Report of an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized MAPCA’s, an extremely rare occurrence.
Surgery for aneurysmal right coronary fistula and constrictive pericarditis Abdulsalam Taha
CRCM, March 2014
View on scirp.org
Abstract:
Coronary artery fistula (CAF) is a direct communication between a coronary artery and the lumen of any of the cardiac chambers, the coronary sinus, the pulmonary artery, the superior vena cava or the proximal pulmonary veins. The majority of these fistulas are congenital in origin although they may occasionally be detected after cardiac surgery. Congenital CAF is a rare anomaly and aneurysmal formation in the fistula is even rarer. Majority of CAF are isolated lesions, however, congenital or acquired heart diseases may coexist. Herein, we report a case of huge congenital aneurysmal right CAF connected to the right atrium in an Iraqi man of 62 associated with tuberculous effusive-constrictive pericarditis to whom off pump pericardiectomy was performed followed by ligation of right coronary artery and vein graft implantation to its posterior descending branch under cardiopulmonary bypass. To the best of our knowledge, such association was not previously reported. CAF can be repaired surgically with minimum risk and excellent outcome. Surgery is advised whenever coronary fistula is diagnosed unless it is very small to avoid the potential complications.
Key words: coronary artery fistula, ectasia, aneurysm, pericarditis, pericardiectomy
Surgery for aneurysmal right coronary fistula and constrictive pericarditis Abdulsalam Taha
CRCM, March 2014
View on scirp.org
Abstract:
Coronary artery fistula (CAF) is a direct communication between a coronary artery and the lumen of any of the cardiac chambers, the coronary sinus, the pulmonary artery, the superior vena cava or the proximal pulmonary veins. The majority of these fistulas are congenital in origin although they may occasionally be detected after cardiac surgery. Congenital CAF is a rare anomaly and aneurysmal formation in the fistula is even rarer. Majority of CAF are isolated lesions, however, congenital or acquired heart diseases may coexist. Herein, we report a case of huge congenital aneurysmal right CAF connected to the right atrium in an Iraqi man of 62 associated with tuberculous effusive-constrictive pericarditis to whom off pump pericardiectomy was performed followed by ligation of right coronary artery and vein graft implantation to its posterior descending branch under cardiopulmonary bypass. To the best of our knowledge, such association was not previously reported. CAF can be repaired surgically with minimum risk and excellent outcome. Surgery is advised whenever coronary fistula is diagnosed unless it is very small to avoid the potential complications.
Key words: coronary artery fistula, ectasia, aneurysm, pericarditis, pericardiectomy
Loops Around the Heart – A Giant Snakelike Right Coronary Artery Ectasia with...komalicarol
Coronary artery dilatation is an uncommon finding and is incidentally found during diagnostic coronary angiography or at necropsy.
The pathogenesis of dilatation of coronary arteries is still not very
well understood and therapeutic strategies are not clear. It is useful to know the difference between aneurysm and ectasia. In this
report we demonstrate the diagnostic workup of an asymptomatic
patient with a remarkable snakelike dilatation of the right coronary
artery with unique convolute. For the first time we used intracoronary injection and simultaneous echocardiographic visualization
of contrast agent (Sonovue) to proof a fistula to the coronary sinus.
Like our patient, most of the patients are asymptomatic in absence
of coronary artery disease and we decided on a conservative approach because of his very complex anatomy
Ulcerative Colitis with Aseptic Abscesses Controlled by Vedolizumab: A Case R...georgemarini
Aseptic abscesses (AAs) are neutrophilic infiltrative lesions that often coincide with systemic inflammatory disorders such as inflammatory bowel diseases (IBD). According to recent literature, medical therapies in IBD with AAs include corticosteroid, immunosuppressants and anti-TNFα biologics.
Prevalence and Determinants of Distress Among Residents During COVID Crisisgeorgemarini
Residents are predisposed to develop distress, burnout, and depression. With COVID-19, new stressful working conditions were imposed. This study aims to assess the impact of COVID-19 on residents’ wellbeing in France.
Patients with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection mainly present severe pneumonia associated with complications related to cytokine storm syndrome. So, it was associated with thrombotic incidents like acute limb ischemia and pulmonary embolism.
Loop –Mediated Isothermal Amplification (LAMP) Based POINT-OF-CARE for Rapid ...georgemarini
Abstract Infectious diseases, including foodborne diseases, to this day remain a major health threat worldwide. Molecular diagnostics, based on nucleic acid (NA) amplification technologies, are in the forefront for the detection of pathogens. Polymerase chain reaction (PCR) is one of the most widely used methods for nucleic acid amplification in pathogen diagnostic.
Wen Dan Tang: A Potential Jing Fang Decoction for Headache Disordersgeorgemarini
Chinese herbal medicine is considered relatively safe, inexpensive, and easily accessible. Furthermore, it is becoming increasingly popular in the western countries. Wen Dan Tang, a Jing Fang ancient classical Chinese herbal formula, with a broad indication profile, has been used for several centuries in China to treat various illnesses.
Abstract Syringoma is a benign eccrine sweat gland tumor affecting mostly females at puberty projected with multiple soft papules usually 1-2 mm in diameter. During puberty, syringoma appears among females; it is presented as multiple soft papules, 1-2 mm in diameter, as a benign eccrine sweat gland tumor. The sites of predilection are lower eyelids, and cheeks. The regions of tendency are cheeks and lower eyelids. Syringoma of the vulvar is a rare disorder few cases of which have been reported in literature.
Rural Healthcare in Light of a Multinational Pandemic: A Global Perspectivegeorgemarini
Abstract Rural healthcare recently came into international spotlight, with recent reported influx of the COVID-19 into rural regions. This article focuses on susceptibilities of the rural population to pandemics and mitigating measures to prevent formation of disease epicentre. Rural Healthcare is by far one of the most neglected areas of medicine. The discrepancies in quality of rural healthcare has been evident for decades, yet no lasting measures have been able to bridge this gap till date. Lessons gleaned from the recent SARS and H1N1 pandemics has once again fallen through the cracks in a futile attempt to curb urban spread. http://dx.doi.org/10.47829/ACMCR.2021.61801
A Mild form of Familial Mediterranean Fever Associated with a Polymorphisms C...georgemarini
Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disease caused bymutation(s) in the Mediterranean fever (MEFV, pyrinmarenostrin) gene. FMF is characterized byrecurrent fever crisis combined with serosal, synovial, or cutìaneous inflammation
Portosystemic Shunt for Treatment of Symptomatic Varices in Polycythemia Vera...georgemarini
Myeloproliferative disorders are commonly associated with portal vein thrombosis, which can lead to extensive and symptomatic variceal disease due to the development of noncirrhotic portal hy- pertension. In severe cases, a decline in liver synthetic function may indicate the need for liver transplantation
A hookah (shisha, waterpipe) use may increase the risk of suffering from serious symptoms due to
COVID-19. Like smoking, hookahs may exacerbate the risk for severe COVID-19 through shared use
and being difficult-to-clean the long pipes and having a cold water reservoir. Social gatherings also
provide an opportunity for the virus to spread.
Can Lung Ultrasound in Patients with Fever of Unknown Origin Detect Early Sig...georgemarini
The increasing interest in Lung Ultrasound (LUS) over the last years led to a great diffusion and better experience in using this technique, which became an essential tool for clinicians. During the current Coronavirus Disease 2019 (COVID-19) pandemic
More Related Content
Similar to A Road from Coronary to Pulmonary: A Rare Imaging Presentation
Loops Around the Heart – A Giant Snakelike Right Coronary Artery Ectasia with...komalicarol
Coronary artery dilatation is an uncommon finding and is incidentally found during diagnostic coronary angiography or at necropsy.
The pathogenesis of dilatation of coronary arteries is still not very
well understood and therapeutic strategies are not clear. It is useful to know the difference between aneurysm and ectasia. In this
report we demonstrate the diagnostic workup of an asymptomatic
patient with a remarkable snakelike dilatation of the right coronary
artery with unique convolute. For the first time we used intracoronary injection and simultaneous echocardiographic visualization
of contrast agent (Sonovue) to proof a fistula to the coronary sinus.
Like our patient, most of the patients are asymptomatic in absence
of coronary artery disease and we decided on a conservative approach because of his very complex anatomy
Ulcerative Colitis with Aseptic Abscesses Controlled by Vedolizumab: A Case R...georgemarini
Aseptic abscesses (AAs) are neutrophilic infiltrative lesions that often coincide with systemic inflammatory disorders such as inflammatory bowel diseases (IBD). According to recent literature, medical therapies in IBD with AAs include corticosteroid, immunosuppressants and anti-TNFα biologics.
Prevalence and Determinants of Distress Among Residents During COVID Crisisgeorgemarini
Residents are predisposed to develop distress, burnout, and depression. With COVID-19, new stressful working conditions were imposed. This study aims to assess the impact of COVID-19 on residents’ wellbeing in France.
Patients with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection mainly present severe pneumonia associated with complications related to cytokine storm syndrome. So, it was associated with thrombotic incidents like acute limb ischemia and pulmonary embolism.
Loop –Mediated Isothermal Amplification (LAMP) Based POINT-OF-CARE for Rapid ...georgemarini
Abstract Infectious diseases, including foodborne diseases, to this day remain a major health threat worldwide. Molecular diagnostics, based on nucleic acid (NA) amplification technologies, are in the forefront for the detection of pathogens. Polymerase chain reaction (PCR) is one of the most widely used methods for nucleic acid amplification in pathogen diagnostic.
Wen Dan Tang: A Potential Jing Fang Decoction for Headache Disordersgeorgemarini
Chinese herbal medicine is considered relatively safe, inexpensive, and easily accessible. Furthermore, it is becoming increasingly popular in the western countries. Wen Dan Tang, a Jing Fang ancient classical Chinese herbal formula, with a broad indication profile, has been used for several centuries in China to treat various illnesses.
Abstract Syringoma is a benign eccrine sweat gland tumor affecting mostly females at puberty projected with multiple soft papules usually 1-2 mm in diameter. During puberty, syringoma appears among females; it is presented as multiple soft papules, 1-2 mm in diameter, as a benign eccrine sweat gland tumor. The sites of predilection are lower eyelids, and cheeks. The regions of tendency are cheeks and lower eyelids. Syringoma of the vulvar is a rare disorder few cases of which have been reported in literature.
Rural Healthcare in Light of a Multinational Pandemic: A Global Perspectivegeorgemarini
Abstract Rural healthcare recently came into international spotlight, with recent reported influx of the COVID-19 into rural regions. This article focuses on susceptibilities of the rural population to pandemics and mitigating measures to prevent formation of disease epicentre. Rural Healthcare is by far one of the most neglected areas of medicine. The discrepancies in quality of rural healthcare has been evident for decades, yet no lasting measures have been able to bridge this gap till date. Lessons gleaned from the recent SARS and H1N1 pandemics has once again fallen through the cracks in a futile attempt to curb urban spread. http://dx.doi.org/10.47829/ACMCR.2021.61801
A Mild form of Familial Mediterranean Fever Associated with a Polymorphisms C...georgemarini
Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disease caused bymutation(s) in the Mediterranean fever (MEFV, pyrinmarenostrin) gene. FMF is characterized byrecurrent fever crisis combined with serosal, synovial, or cutìaneous inflammation
Portosystemic Shunt for Treatment of Symptomatic Varices in Polycythemia Vera...georgemarini
Myeloproliferative disorders are commonly associated with portal vein thrombosis, which can lead to extensive and symptomatic variceal disease due to the development of noncirrhotic portal hy- pertension. In severe cases, a decline in liver synthetic function may indicate the need for liver transplantation
A hookah (shisha, waterpipe) use may increase the risk of suffering from serious symptoms due to
COVID-19. Like smoking, hookahs may exacerbate the risk for severe COVID-19 through shared use
and being difficult-to-clean the long pipes and having a cold water reservoir. Social gatherings also
provide an opportunity for the virus to spread.
Can Lung Ultrasound in Patients with Fever of Unknown Origin Detect Early Sig...georgemarini
The increasing interest in Lung Ultrasound (LUS) over the last years led to a great diffusion and better experience in using this technique, which became an essential tool for clinicians. During the current Coronavirus Disease 2019 (COVID-19) pandemic
Postpartum Meningitis by Enterococcus Faecalis Secondary to Neuraxial Anesthesiageorgemarini
Meningitis is an infrequent and serious cause of postpartum fever that requires early diagnosis and treatment to prevent serious complications and to reduce the high mortality rate. Neuraxial anesthesia is a frequently used technique in obstetrics. Meningitis is a very rare complication of neuraxial an- esthesia and enterococcus....
Advanced Esophagogastric Cancer after Bariatric Proceduregeorgemarini
A 74-year-old man, non-smoker or alcoholic, underwent gastric bypass with stapled division of the stomach and Roux-en-Y gastrojejunostomy 20 years ago. A band was used to limit the emptying of the gastric pouch. Follow up was abandoned there are ten years, and, three months ago,
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...georgemarini
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy....
Superior Mesenteric Artery Syndrome Treated by Laparoscopic Duodenojejunostomygeorgemarini
Superior Mesenteric Artery syndrome (SMA Sd) is a very rare disease. It is suspected in the case of intestinal obstruction in severely underweight patients
Colopleural Fistula. A Case Report and Review of Literaturegeorgemarini
The presence of a colopleural fistula is a rare event related to several factors, inadequate placement of drains, poor surgical technique, infection or dehiscence of a GI anastomosis
Atypical Presentation of Post-Kala Azar Dermal Leishmaniasis in Bhutangeorgemarini
This article describes an atypical case of post-kala azar dermal leishmaniasis associated with complications due to delayed diagnosis and poor case management. The grave consequences of the prolonged disease process, which included facial disfigurement
Cutaneous Larva Migrans: A Case Report in a Traveler Childgeorgemarini
Cutaneous Larva Migrans (CLM) is the most common skin disease of tropical origincaused by hookworms larvae, occurring in international travelers. Typical manifestations consist of erythematous, serpiginous slightly elevated linear cutaneous lesions
Since receiving unexplained pneumonia patients at the Jinyintan Hospital in Wu- han, China in December 2019, the new coronavirus (COVID-19) has rapidly spread in Wuhan, China and spread to the entire China and some neighboring countries.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. http://www.acmcasereport.com/ 2
Volume 8 Issue 17 -2022 Case Report
severe pulmonary arterial hypertension was present.
A Cardiac CT was advised as a routine pre-operative investigation
to evaluate the pulmonary vasculature and ascertain the presence
of MAPCA’s.
A retrospective ECG-gated Cardiac CT was performed on a 64
slice Multidetector Computed Tomography (MDCT) scanner
(Brilliance Philips ) in a helical mode followed by retrospective
2D and 3D reconstruction (MPR &MIP). The contrast images were
obtained after injection of 90 ml of iodinated non-ionic contrast by
bolus triggering. A venographic phase was also obtained including
the upper abdomen to assess concomitant venous anomalies.
The Cardiac CT confirmed the echocardiographic findings of a
large sub-aortic VSD with over-riding of aorta by approximately >
50% (Figure 2A and 2B) and complete atresia of pulmonary valve
and main pulmonary artery (Figure 2C).
A small PDA was seen arising from inferior surface of arch of
aorta and communicating with the left main pulmonary artery with
severe junctional stenosis (Figure 3A, 3B and 3C).
Additionally, it was observed that the left main coronary artery
(LMCA) was dilated with a large tortuous collateral (CAPA/
CFAP) arising from it after the origin of LCx and LAD, further
communicating with right main pulmonary artery, thus providing
the major source of supply to the right pulmonary circulation (Fig-
ure 4A,4B,4C and 4D). The distal pulmonary arteries were moder-
ately narrowed in calibre.
Apart from this, multiple dilated and tortuous collaterals (MAP-
CA’s) were also noted in the mediastinum arising from the arch
and descending aorta and coursing into bilateral lungs via lung
hilum (Figure 5A). The largest of these collaterals (9.2 mm in di-
ameter) was seen arising from the right lateral wall of the descend-
ing thoracic aorta at the D8 vertebral level to the right ascending
pulmonary artery (Figure 5B).
The LMCA showed normal division into the Left Anterior De-
scending artery (LAD) and Left Circumflex artery (LCX) which
had normal course and calibre. The Right Coronary Artery (RCA)
was seen to arise from the right coronary cusp and showed normal
calibre and course.
An evaluation of the cardiac chambers showed mild concentric
hypertrophy of right ventricle with dilated right atrium.
Figure 1: Frontal topograph demonstrates a boot-shaped heart with an uplifted apex secondary to RV hypertrophy and dilated ascending aorta causing
bulge of right heart border above right atrium.
Figure 2A and 2B: Cardiac CT images showing a sub-aortic VSD with over-riding of aorta by approximately > 50% (white arrows).
3. http://www.acmcasereport.com/ 3
Volume 8 Issue 17 -2022 Case Report
Figure 2C: Reconstructed VRT images showing complete pulmonary atresia.
Figure 3: Reconstructed coronal MIP (3A) and axial images (3B) showing persistent PDA arising from arch of aorta communicating with LPA with
severe junctional stenosis (white arrows).
Figure 3C: Reconstructed VRT images showing the PDA communicating with LPA (white arrow).
4. http://www.acmcasereport.com/ 4
Volume 8 Issue 17 -2022 Case Report
Figure 4: Sequential contrast axial images (4A, 4B, 4C) and reconstructed VRT (4D) images showing dilated LM with a large collateral communicating
with RPA (white arrows). Reconstructed VRT (4D) images also shows LAD and LCx arising from LM (blue arrows).
Figure 5A and 5B: Multiple dilated and tortuous MAPCA’s with largest collateral (white arrow) arising from right lateral wall of aorta.
4. Discussion
Tetralogy of Fallot (TOF) is the most common cyanotic congenital
heart disease with an estimated worldwide prevalence of 3 cases
per 10,000 live births [4]. It is a conotruncal defect which occurs
due to an anterior malalignment of the infundibular septum which
is responsible for the four main components [5] (Figure 6).
a). Ventricular Septal Defect (VSD)
b). Pulmonary Infundibular Stenosis
c). Over-riding of aorta.
d). Right ventricular hypertrophy.
The association of TOF with an Atrial Septal Defect (ASD) or Pat-
ent Ductus Arteriosus (PDA) classifies it as a Pentalogy of Fallot,
as was visualized in this case.
The clinical presentation of these patients as well as their prognosis
predominantly depends on the degree of obstruction to pulmonary
blood flow, whether hypoplastic, severely stenotic or completely
atretic pulmonary valve and pulmonary arteries [6]. In such cases
Multiple Abnormal Vascular Channels (MAPCA’s) [7, 8] develop
from the thoracic aorta, abdominal aorta, subclavian artery, bron-
chial and intercostal arteries which are connected to the pulmonary
arterial vasculature distally, thereby maintaining the pulmonary
blood flow and reducing the chances of pulmonary infarction.
However, in rare cases, coronary arteries, i.e. Right Coronary Ar-
tery (RCA), Left Main Coronary Artery (LMCA) or its branches
Left Anterior Descending artery (LAD) and Left Circumflex artery
(LCX) can be a source of pulmonary blood flow [9].
Amin et al. [10] hypothesized that a communication between the
coronary and pulmonary artery is physiologically and embryolog-
ically more similar to a ductus arteriosus than to systemic–pulmo-
nary collaterals as this communicates in an antegrade fashion with
the central pulmonary arteries. Sometimes a coronary to pulmo-
nary artery communication with sufficient calibre can become the
primary source of pulmonary blood flow in patients with PA/VSD.
5. http://www.acmcasereport.com/ 5
Volume 8 Issue 17 -2022 Case Report
In this setting, whether such a communication should be referred
to as a CAPA or fistula (CPAF) can be put up for debate. [11].
The estimated incidence of such Coronary Artery to Pulmonary
Artery Collaterals (CAPA) ranges from 1.3% to 10% [12]. To date,
52 cases of PA/VSD with CPAP have been reported in literature.
The CPAP involved the LMCA in 34 cases, RCA in 12 cases, a
single coronary artery in 5 cases, and both coronary arteries in 2
cases [11]. Mittal and colleagues [13] reported a case of a large fis-
tula between the left anterior descending artery and the pulmonary
artery in a patient with TOF. Another report describes a collateral
communication between the left circumflex artery and the right
pulmonary artery [14].
However, to the best of our knowledge, this is the first case with
presence of multiple sources of pulmonary blood flow, i.e. LMCA
to right pulmonary artery, PDA to left pulmonary artery and mul-
tiple dilated and tortuous MAPCAs from descending aorta and bi-
lateral bronchial arteries.
The demonstration of such anomalous collateral pathways remains
difficult and requires an invasive investigation such as Coronary
ArteryAngiography for their adequate detection. However, knowl-
edge of existence of these variations can aid in their prompt detec-
tion on a simple non-invasive Cardiac CT as well, as was in our
case. This can obviate the need for diagnostic invasive procedures,
directly guiding the cardiac surgeons to plan surgical treatment of
choice accordingly.
Determining the presence of collaterals has implications in man-
agement of such patients as well. Ever since the introduction of
the concept of early one staged unifocalization in the surgical
management of patients with PA/VSD, accurate delineation of all
the sources of pulmonary blood flow has become the most critical
step of the preoperative evaluation [15]. The main aim of treat-
ment strategy is to recruit as many lung segments as possible into
the pulmonary circulation. This case demonstrates the interdepen-
dence of size of CAPA and the number of MAPCA’s supplying the
pulmonary bed. The CAPA/CPAF is addressed surgically depend-
ing on the distal artery with which it connects. If the distal end of
the CAPA is connected to the MPA, it is ligated and divided. If the
distal end is connected to the right or left pulmonary arteries (as in
our case) it is unifocalized.
The findings of Cardiac CT in our case thus helped guide the cardi-
ac surgeon in planning a multistage treatment procedure.
The detection of coronary artery abnormalities has clinical impli-
cations as well. When the coronary artery drains into the capillary
networks of the lungs, ‘coronary artery steal’ phenomenon can re-
sult which could cause myocardial ischaemia. However, this con-
dition may also develop pulmonary hypertension and heart failure
due to the haemodynamic effect of the left-to-right shunt. Hence,
detection of the presence of these coronary artery to pulmonary
artery connections has both prognostic as well as diagnostic im-
plications.
Figure 6: Schematic diagram showing components of Tetralogy of Fallot
5. Conclusion
Congenital cardiac diseases belong to a complex group of diseas-
es and knowledge of their myriad of presentations has an import-
ant bearing on the overall physical and mental health of patients.
With the advent of newer generation MDCT scanners, presence
of various systemic–pulmonary as well as coronary-pulmonary
collaterals can be delineated in a non-invasive manner with the
added advantage of detection of extracardiac anomalies as well,
thus obviating the need for invasive procedures such as catheter
angiography.
6. http://www.acmcasereport.com/ 6
Volume 8 Issue 17 -2022 Case Report
References
1. Talner CN. Report of the New England regional infant cardiac pro-
gram, by Donald C. Fyler, MD, Pediatrics. 1980; 65(suppl): 375-461.
2. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J
Am Coll Cardiol. 2002; 39: 1890-900.
3. Marelli AJ, Mackie AS, Ionescu Ittu R, Rahme E, Pilote L. Congeni-
tal heart disease in the general population: Changing prevalence and
age distribution. Circulation. 2007; 115: 163-72.
4. Parker SE, Mai CT, Canfield MA, et al. for the National Birth Defects
Prevention Network. Updated national birth prevalence estimates for
selected birth defects in the United States, 2004-2006. Birth Defects
Res A Clin Mol Teratol. 2010; 88: 1008-16.
5. Diaz-Frias J, Guillaume M. Tetralogy of Fallot. [Updated 2022 Jan
18]. In: StatPearls [Internet]. Treasure Island (FL).
6. Marino B, Calabró R, Gagliardi MG, Bevilacqua M, Ballerini L,
Marcelletti C. Patterns of pulmonary arterial anatomy and blood sup-
ply in complex congenital heart disease with pulmonary atresia. J
Thorac Cardiovasc Surg. 1987; 94(4): 518-20.
7. Reddy VM, Liddicoat JR, Hanley FL. Midline one-stage complete
unifocalization and repair of pulmonary atresia with ventricular sep-
tal defect and major aortopulmonary collaterals. J Thorac Cardiovasc
Surg. 1995; 109: 832-45.
8. Liao P, Edwards WD, Julsrud PR, Puga FJ, Danielson GK, Feldt RH.
Pulmonary blood supply in patients with pulmonary atresia and ven-
tricular septal defect. J Am Coll Cardiol. 1985; 6: 1343-50.
9. Krongrad E, Ritter DG, Hawe A, Kincaid OW, McGoon DC. Pul-
monary atresia or severe stenosis and coronary artery to pulmonary
artery fistula. Circulation. 1972; 26: 1005-12.
10. Amin Z, McElhinney DB, Reddy VM, Moore P, Hanley FL, Teitel
DF, et al. Coronary to pulmonary artery collaterals in patients with
pulmonary atresia and ventricular septal defect. Ann Thorac Surg.
2000; 70: 119-23.
11. Alkhushi N, Al Radi OO, Ajlan A, Abdelmohsen G, Attia W. Coro-
nary pulmonary arterial fistula in a neonate with pulmonary atresia
ventricular septal defect and single coronary artery. Echocardiogra-
phy .2017; 34: 1536-9.
12. Sathanandam SK, Loomba RS, Ilbawi MN, Van Bergen AH. Coro-
nary artery to pulmonary artery fistula in a case of pulmonary atresia
with ventricular septal defect. Pediatr Cardiol. 2011; 32: 1017-22.
13. Mittal, Chander Mohan et al. A case of tetralogy of Fallot associated
with left anterior descending coronary artery to pulmonary artery fis-
tula. Annals of pediatric cardiology. 2011; 4: 202-3.
14. Agarwal S, Mishra BB, Mukherjee K, Satsangi DK. Coronary-to-pul-
monary artery collateral in tetralogy of Fallot. Asian Cardiovasc
Thorac Ann. 2009; 17: 304-6.
15. Reddy VM, McElhinney DB, Amin Z, Moore P, Parry AJ, Teitel DF,
et al. Early and intermediate outcomes after repair of pulmonary atre-
sia with ventricular septal defect and major aortopulmonary collat-
eral arteries: Experience with 85 patients. Circulation. 2000; 101:
1826 3.