thexraydoctor ### Case Description This is the CT image from my last post (with the chest X-ray too). Key findings were: small sternotomy wires for an adult, meaning they were from childhood surgery, right sided aortic arch and huge pulmonary arteries. This is #Tetralogy-of-Fallot corrected in childhood but with complication of pulmonary stenosis and #Regurgitation. 25% have a right sided arch. --- ### Similar cases Frontal chest radiograph shows asymmetric pulmonary edema with a hazy appearance of the right lung and indistinctness of the pulmonary vascularity. Asymmetric pulmonary edema is more common on the right side and associated with mitral regurgitation. Other factors associated with asymmetric edema include patient positioning, pulmonary vein occlusion, and right to left shunt. An 11-year-old boy was admitted to the intensive care unit with respiratory distress and expectoration of bronchial casts every few days. He had a history of dextro-transposition of the great arteries (D-TGA) with ventricular septal defect (VSD) and coarctation of the aorta, for which he underwent neonatal arch repair, an arterial switch operation and VSD repair. The operations were complicated by a long period of renal failure, from which he recovered. Subsequently, he underwent five more sternotomies to address the following issues: - Regurgitation of both semilunar valves - Subvalvar and supravalvar stenosis - Recurrent arch obstruction - Bilateral branch pulmonary artery stenosis At age 9 years, he required the following additional surgeries: - Anterior aortoventriculoplasty with implantation of a 21-mm mechanical aortic valve - Right ventricular muscle bundle resection - Replacement of the pulmonary valve and proximal branch pulmonary artery branches with a bifurcated pulmonary homograft Over the prior two years, he developed severe tricuspid regurgitation, elevated right ventricular pressures, and severe homograft valve regurgitation with mild stenosis of the branch pulmonary arteries. Despite having no related symptoms, his liver had been 4 cm below the right costal margin. Until this presentation, he had been relatively stable on diuretic therapy. Physical examination at presentation was particularly remarkable for an even more enlarged liver (5.5 cm below the right costal margin) and pronounced jugular venous distention. Cardiac catheterization confirmed elevated right-sided diastolic pressures. MR lymphangiogram revealed collateralization of obstructed lymphatic vessels. The team adopted a staged approach in which the pulmonary artery and pulmonary valve issues were first corrected, as these could be approached percutaneously. The patient underwent left pulmonary artery stenting and transcatheter pulmonary valve replacement. Despite that, he progressed to daily cast formation and respiratory failure. The decision-making at this point was to proceed to a more invasive strategy to address the remaining right-sided lesions. He underwent surgical repair of the tricuspid valve, with improvement of his right-sided pressures. Axial chest CT with contrast shows a pulmonary sling with the left pulmonary artery arising from the right main pulmonary artery and traveling posterior to the distal trachea. Note that the trachea is small in caliber with a circular shape. Pulmonary sling is associated with complete tracheal rings as in this patient. Volumetric 3-D reconstruction viewing from posterior to anterior shows the relationship of the aorta, pulmonary artery, and tracheobronchial tree. Chest x-ray and chest CT show a right-sided aortic arch. Both studies show the right-sided arch displacing the trachea to the left. Right-sided aortic arches occur in 0.1-0.2% of the population. There are two common types of right-sided aortic arch categorized by the branching pattern of the great vessels: a right-sided aortic arch with mirror image branching and a right-sided aortic arch with an aberrant left subclavian artery. The right-sided aortic arch with mirror imaging is associated with other T-lesions of the heart including tetralogy of Fallot, transposition of the great vessels, truncus arteriosus, and tricuspid atresia. --- ### Trending now A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department. A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area. A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest. Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?