Diagnosis of anomalous origin of the right subclavian artery from the right pulmonary artery in a patient with D‐transposition of the great arteries utilizing transthoracic echocardiography

Abstract

Diagnosis of anomalous origin of the right subclavian artery (AORSA) from the right pulmonary artery (RPA) is usually made using CT, MRI, or invasive angiography. We report a patient diagnosed using transthoracic echocardiography (TTE). A newborn girl prenatally known to have d-TGA presented with cyanosis sparing the right hemithorax and arm. Oxygen saturations on the right hand were persistently higher than on the right ear and other extremities. Repeat TTE using a modified echocardiographic imaging plane allowed for full visualization of the entire subclavian artery course, revealing AORSA from RPA. We discuss further the approach to echocardiographic diagnosis and surgical implications.

Left Subclavian Artery Isolation with Right Aortic Arch and D-Transposition of the Great Arteries

“…2 Isolation of the subclavian artery in association with d-TGA is rarer still. Investigators describe several case reports of isolated right subclavian artery from the right pulmonary artery with d-TGA [3][4][5][6][7][8][9] and only two reports of an isolated left brachiocephalic with d-TGA. 10,11 There are two reports of an isolated LSA with d-TGA, by Byrum et al, 12 who described the diagnosis confirmed by cardiac catheterization with angiography, and Siddartha et al, 13 who described a patient with d-TGA who underwent an arterial switch operation on the fourth day of life.…”

“…The diagnosis is most commonly made by cardiac computed tomography, CMR, or invasive angiography. However, it can be made by echocardiography 4 and requires thorough interrogation of the branching pattern of the head and neck vessels. Although arch sidedness and branching are classically defined in the suprasternal axial view with a sweep superiorly, locating the origin of an anomalous subclavian artery requires slow sweeps inferiorly to visualize the main and branch pulmonary arteries, as described by Makadia et al 4 Thus, when arch branching anatomy is unclear from typical suprasternal sweeps, further evaluation of each head and neck vessel's origin is necessary to define the anatomy.…”

“…However, it can be made by echocardiography 4 and requires thorough interrogation of the branching pattern of the head and neck vessels. Although arch sidedness and branching are classically defined in the suprasternal axial view with a sweep superiorly, locating the origin of an anomalous subclavian artery requires slow sweeps inferiorly to visualize the main and branch pulmonary arteries, as described by Makadia et al 4 Thus, when arch branching anatomy is unclear from typical suprasternal sweeps, further evaluation of each head and neck vessel's origin is necessary to define the anatomy. In our case, on review of the postnatal echocardiogram after the diagnosis was made, there were supraclavicular and subcostal views in which the LSA could be seen originating from the LPA (Figures 4 and 5, Videos 4 and 5).…”

“…Isolation of the subclavian artery in association with d-TGA is rarer still. Investigators describe several case reports of isolated right subclavian artery from the right pulmonary artery with d-TGA 3 , 4 , 5 , 6 , 7 , 8 , 9 and only two reports of an isolated left brachiocephalic with d-TGA. 10 , 11 There are two reports of an isolated LSA with d-TGA, by Byrum et al.…”