Medical Image of the Week: Fontan Procedure

Figure 1. Thoracic CT scan showing Fontan anatomy, with the superior vena cava (SVC) connected to the pulmonary arteries (yellow arrow) and a single atrium and ventricle (red arrow).

Figure 2. SVC venography shows SVC connected to the pulmonary artery.

A 25-year-old man with a history of transposition of the great vessels (L-TGA) was admitted for persistent hemoptysis. He had a history of a double inlet left ventricle, pulmonary hypertension and was postoperative for a Fontan procedure completed at age of 2. No anatomical source for the hemoptysis was found.  A thoracic CT showed the Fontan anatomy: SVC connected to the pulmonary artery as per the Glenn connection (IVC drained to right pulmonary artery through the Fontan pathway) and a single ventricle and atrium (Figure 1). SVC venography showed the SVC connected to the pulmonary artery (Figure 2). The hemoptysis resolved after started sidenafil and bosentan for pulmonary hypertension.

Mohammed Alzoubaidi MD, Carmen Luraschi Monjagatta MD, Maria Tumanik DO, Naomi Jean Young MD

University of Arizona

Department of Pulmonary and Critical Care Medicine

Internal Medicine, South Campus.

Family Medicine, South Campus

Tucson, AZ

Reference as: Alzoubaidi M, Monjagatta CL, Tumanik M, Young NJ. Medical image of the week: Fontan procedure. Southwest J Pulm Crit Care. 2013;7(2):112-3. doi: http://dx.doi.org/10.13175/swjpcc114-13 PDF

Medical Image of the Week: Metastatic Melanoma with Hemorrhage

Figure 1. Axial image of CT Chest with contrast showing pulmonary metastatic masses and alveolar opacities consistent with pulmonary hemorrhage.

Figure 2. Coronal image of CT Chest with contrast showing innumerable pulmonary nodules and masses along with ground-glass alveolar opacities representing alveolar hemorrhage.

A 62 year-old gentleman presented with right leg swelling due to an extensive DVT in the right femoral vein.  He was found to have a right groin mass attributed to metastatic malignant melanoma.  Chest X-ray and CT revealed multiple bilateral pulmonary nodules.  He was started on warfarin 3mg daily for acute DVT and referred to Oncology.  2 weeks later he developed hemoptysis and was found to be hypoxemic.  He was admitted to our MICU.  His INR upon admission was 8.2 and hemoglobin 6.4.  CT Chest showed innumerable bilateral pulmonary nodules and ground-glass alveolar opacities with thickening and nodularity of intra-lobular septa adjacent to the nodules.  Warfarin was held and packed RBC and FFP transfusions were given with progressive improvement in hemoptysis and pulmonary status.

Tauseef Afaq Siddiqi, MD; Abdulmajid Eddib, MD; Phillip Factor, DO; and Steven Knoper, MD

Department of Medicine

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ 85724, USA

Reference as: Siddiqi TA, Eddib A, Factor P, Knoper S. Medical image of the week: metastatic melanoma with hemorrhage. Southwest J Pulm Crit Care. 2013;6(6):287-8. http://dx.doi.org/10.13175/swjpcc079-13 PDF