Congenital Aortic Arch Abnormality in Tetralogy of Fallot: A Rare Case Report

Abstract

A 4-year-old male child was referred to the pediatrics department of our hospital from an Anganwadi with
complaints of easy fatigability compared to peers, dyspnea on normal exertion and refusal to feed for 10 days.
There was no history of palpitation, bluish discoloration, pedal edema, abdominal distention, cough, or
orthopnoea. On auscultation, a grade 2 end systolic murmur was heard. Full blood count revealed an Hb 10 g/dl,
MCV 67.2 fL, MCH 20.9 and HCT 32.1%. Liver and kidney function tests were within normal limits. However, the
Total T3 (2.85 nmol/L) and TSH were elevated (9.30 mmol/L).

Chest X-ray indicated cardiomegaly with right ventricular enlargement with clear lung fields and pleural
spaces. ECG further showed right axis deviation and enlargement of the right ventricle. He was diagnosed with
Tetralogy of Fallot on 2D Echo, having confluent good-sized pulmonary arteries (Macgoon’s ratio: 1:4), large
malaligned VSD with BD shunt, severe valvular and subpulmonary annular stenosis. These findings were further
confirmed on MDCT chest with pulmonary angiography. Furthermore, bilateral anomalous origin of both right
and left vertebral arteries from the arch of aorta was also observed. Later the patient was scheduled for elective
surgical repair. Sauvage patch closure of VSD was done with 5-O continuous prolene sutures followed by
reconstruction of the RVOT by augmenting it with a pericardial patch.

The postoperative course was uneventful with minimal drainage. The patient was discharged on Injection
Ceftumand Injection Lefoflox with infective endocarditis prophylaxis.
In this case, we aimed to discuss the diagnostic implications of variations in the aortic arch with a special
focus on the imaging and approach to the management.

Keywords: Vertebral arteries anomalies; Implications and Diagnosis; Arch of aorta anomalies;
Ceftumand injection