PMC6366150_01
Postero-anterior (A) and lateral (B) chest radiographs. A curvilinear tubular opacity (arrows) is seen in the right lung base anteriorly corresponding to the anomalous pulmonary vein on cross-sectional imaging. No appreciable right lung volume loss is seen.
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Her initial evaluation at our facility included a chest X-ray (Fig. 1) computed tomography (CT) scan of the chest with intravenous contrast and three-dimensional reconstruction (Fig. 2).
Cardiac magnetic resonance and magnetic resonance angiography. 4-chamber long axis bright blood images in ventricular systole (A) and ventricular diastole (B) demonstrate right atrial (RA, A) and right ventricular (RV, B) enlargement with diastolic flattening of the interventricular septum in diastole indicative of increased right ventricular volumes. Post-contrast axial image (C) shows enlargement of the central pulmonary arteries and coronal maximum intensity projection image (D) demonstrates the large anomalous pulmonary vein (arrow) draining the right upper and right middle lobes to the inferior vena cava.
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Cardiac MR (obtained previously) showed right chamber enlargement and evidence of left to right shunting. (Fig. 3).
(A) Significant obstruction of the right mainstem bronchus with quiet breathing. (B) The right upper lobe bronchus appears to come off of the bronchus intermedius anteriorly.
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Bronchoscopy demonstrated additional abnormalities in her tracheobronchial tree anatomy (Fig. 4).
Contrast-enhanced computed tomography. Sagittal oblique image (A) demonstrates mass effect by the enlarged right pulmonary artery on the origin of the right upper lobe bronchus (arrow) and immediate trifurcation of the right mainstem bronchus. Coronal oblique image (B) demonstrates the proximity of the enlarged right pulmonary artery to the proximal right upper lobe bronchus inferiorly. Axial minimum intensity projection image (C) demonstrates the branching of the right mainstem bronchus with a diminutive right middle bronchus (arrow).
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As can be seen in Fig. 5, she did however appear to have RUL takeoff obstruction from her enlarged scimitar vein.