Ann Thorac Surg 2009;87:1297. doi:10.1016/j.athoracsur.2008.07.081
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Coronary to Pulmonary Collateral in Tetralogy of Fallot with Pulmonary Stenosis
Vikas Sharma, MS*,
Shyam K.S. Thingnam, Mch
Department of Cardiovascular and Thoracic Surgery, Post Graduate Institute of Medical Sciences and Research, Chandigarh, India
* Address correspondence to Dr Sharma, Department of Cardiovascular and Thoracic Surgery, Post Graduate Institute of Medical Sciences and Research, Sector 12, Chandigarh, 160012, India (Email: mbbsmsmch{at}yahoo.com).
Major aortopulmonary collaterals are present in less than 5% of patients with tetralogy of Fallot with pulmonary stenosis, of which coronary to pulmonary collaterals are rare [1].
A 12-year-old girl presented with cyanosis, breathlessness, and cyanotic spells since age 2 years. Clinical examination was suggestive of tetralogy of Fallot. Her hemoglobin level was 22 g/dL and room air saturation was 66%. Echocardiography revealed a 21-mm subaortic ventricular septal defect with 40% aortic override, right ventricular outflow gradient (RVOT) of 70 mm Hg, and pulmonary annulus of 12 mm. Cardiac catheterization revealed equated systolic ventricular pressures of 102 mm Hg and a RVOT gradient of 80 mm Hg, and infundibular, valvular, and supravalvular stenosis with confluent pulmonary arteries.
An angiogram showed 3 major aortopulmonary collaterals from the descending thoracic aorta. A coronary angiogram revealed a large coronary artery branch, which was larger than the left anterior descending artery and the left circumflex artery, arising from left main bifurcation, coursing behind the aorta, and ramifying in right hilum (Fig 1, arrow). In addition, small collaterals from the distal left anterior descending and left circumflex were also present.
She underwent intracardiac repair-patch closure of ventricular septal defect, infundibular resection with transannular patching, and ligation of systemic collaterals. A coronary-to-pulmonary collateral was identified running intramuscularly on the roof of left atrium by inspection and palpation. This collateral was temporarily clamped for 10 minutes. No electrocardiogram or hemodynamic changes were noted, and it was ligated before the patient was placed on cardiopulmonary bypass.
The patient had an uneventful recovery. She has been on regular follow-up and is doing well.
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References
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- Kirklin JW, Barratt-Boyes BG. Ventricular septal defect with pulmonary stenosis or atresiaIn: Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB, editors. Cardiac surgery: morphology, diagnostic criteria, natural history, techniques, results, and indicator. 3rd ed.. Philadelphia: Churchil Livingstone; 2003. pp. 946-1074.
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