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7 month old, male Labrador mix. The patient presented with a history of syncope and seizure like activity. Physical examination revealed weak femoral pulses with bilateral grade IV/VI basilar systolic murmur, which were better auscultated on the left than on the right side.

Radiography - R lateral and DV radiograph of the thorax.

Computed tomography - Axial images of the thorax with 0.5 mm slice thickness before and after intravenous iodinated contrast injection (arterial and venous phase) are available for interpretation. Dorsal and sagittal reconstructed images of the thorax are included. Additional a 3D reconstruction of the heart and vessels is available.

Radiology report thorax – Mild to moderate enlargement of the cardiac silhouette with an increased sternal contact is present. Mild elevation of the bifurcation of the trachea. Mild widening of the cranial mediastinum and a small triangular soft tissue density is visible in the cranial mediastinum.

CT report thorax - The thymus is large, consistent with the given age of the patient. There is evidence of right atrial enlargement, right ventricular hypertrophy and enlargement of the main pulmonary artery, consistent with pulmonic stenosis. There is marked narrowing and irregular contrast filling of the pulmonary artery just distal to the dilated portion. There is a type R2A malformation of the coronary arteries, with a single coronary artery leaving the aorta which then branches and the left branch appears to branch again so that 2 vessels course cranial to the pulmonary trunk at the level of the compression.

Diagnosis

Radiology findings - Mild to moderate right-sided cardiac enlargement. The small soft tissue density in the cranial mediastinum likely represents a remnant of the thymus or an overlying skin fold.

Discussion

Subvalvular stenosis associated with coronary artery anomaly is most commonly seen in English bulldogs and Boxer breeds. The R2A type of coronary artery malformation is a single right coronary artery, which gives rise to the left coronary artery. This left coronary artery encircles the base of the main pulmonary artery at the level of the pulmonic annulus and can also constrict the right ventricular outflow tract close to the level of the pulmonic valve contributing to pulmonic stenosis.

Patients with this form of abnormality are usually at high risk for rupturing the aberrant coronary artery if a balloon dilation or graft surgery is attempted to correct the pulmonic stenosis and it is therefore not recommended. Additionally they might have a diminished coronary blood flow, which can result in the death of the patient if balloon dilation is attempted.(1)

CT findings – Aberrant coronary artery with subvalvular pulmonic stenosis. The left branch of the coronary artery wraps around the main pulmonary artery in a type R2A malformation.