Interact CardioVasc Thorac Surg 2008;7:510-511. doi:10.1510/icvts.2007.174516
© 2008 European Association of Cardio-Thoracic Surgery
Surgical repair of aortico-left ventricular tunnel arising from the left aortic sinus
Masamichi Onoa,*,
Heidi Goerlera,
Dietmar Boethigb and
Thomas Breymanna
a Division of Cardiac, Thoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
b Division of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
Received 13 January 2008;
received in revised form 5 February 2008;
accepted 6 February 2008
*Corresponding author. Tel.: +49-511-532-9397; fax: +49-511-532-9832.
E-mail address: Ono.Masamichi{at}MH-Hannover.de (M. Ono).
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Abstract
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Aortico-left ventricular tunnel is a rare congenital cardiac defect, which bypasses the aortic valve via the paravalvar connection from the left ventricle to the aorta. In most of the cases, the tunnel arises from the right aortic sinus. We herein report a case of aortico-left ventricular tunnel, of which the aortic orifice was arising from the left aortic sinus, requiring special attention for avoiding left coronary artery injury at the time of surgical repair.
Key Words: Aortico-left ventricular tunnel; Aortic insufficiency; Coronary artery
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1. Introduction
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Aortico-left ventricular tunnel (ALVT) is a rare congenital heart anomaly presenting paravalvar communication between the ascending aorta and the left ventricle, for which surgical closure has been recommended at the time of diagnosis due to inadequacy of medical therapy. Since the first surgical treatment reported by Levy and colleagues in 1963 [1], approximately 100 cases of ALVT were reported. According to the literature review [2–4], the aortic orifice is mostly opened from the right coronary sinus, and the right coronary artery is occasionally involved in the tunnel requiring special consideration for surgical repair. We report herein an extremely rare case of ALVT in which the aortic orifice arose from the left sinus requiring special care for avoiding left coronary artery injury at the time of surgical repair.
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2. Clinical summary
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A 10-month-old baby was admitted for the diagnosis of severe aortic regurgitation. Echocardiography demonstrated trivial regurgitant flow through aortic valve and a tubular communication between the ascending aorta and the left ventricle bypassing the aortic valve showing massive regurgitate flow (Fig. 1a,b). The left ventricle was moderately dilated, but ventricular function was preserved with a fraction shortening of 39%. Cardiac catheterization confirmed a runoff of contrast material from the left ventricular outflow tract through a tunnel into the ascending aorta (Fig. 1c).
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Fig. 1. Pre-operative still images from echocardiogram and cardiac angiogram. Long-axis view of echocardiogram showing a tubular communication between the ascending aorta and the left ventricle (a), and showing massive regurgitate flow (b). Selective antegrade left ventricular outflow tract angiography in frontal projection demonstrates an aortico-left ventricular tunnel located left-lateral and posterior to the ascending aorta (c).
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An elective operation was performed with cardiopulmonary bypass and moderate hypothermia (27°). After the aorta was cross-clamped and incised horizontally, inspection from inside and outside of the aortic wall revealed that the tunnel was located on the posterior aspect and leftwards of the aorta close to the left coronary artery (Fig. 2a). The myocardial protection was achieved by selective administration of cold crystalloid cardioplegia. The aortic opening of the tunnel arose from the left coronary sinus at the level of sinotubular junction (Fig. 2b), and the tunnel lay between the left coronary artery and the ascending aorta. As the aortic orifice was slit-like and thick, primary closure of the aortic orifice was performed with extra care so as not to injure the left coronary artery (Fig. 2c). Then, plication of the tunnel was added (Fig. 2d). After closure of the aortic incision and de-clamping the aorta, the patient was weaned from cardiopulmonary bypass without any difficulty. Intra-operative trans-esophageal echocardiography showed complete closure of the tunnel with no aortic valve regurgitation. The patient was discharged home on the 6th postoperative day, and trans-thoracic echocardiography at three months of follow-up demonstrated trivial aortic insufficiency.
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Fig. 2. Intra-operative pictures as seen from the surgeon's view after cardiac arrest. (a) ALVT was located posteriorly to the ascending aorta. (b) The aortic orifices arose from the left aortic sinus. There was a fusion between the right and left aortic cusps. (c) After direct closure of the aortic orifice of AVLT, patency of the LCA was confirmed. (d) Tunnel obliteration was concomitantly performed. (ALVT, aortico-left ventricular tunnel; LCA, left coronary artery.)
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3. Discussion
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The incidence of ALVT is low. Martins et al. reported it was 0.001% in patients with congenital heart disease at their institutions experience [2]. There were approximately 100 patients with ALVT reported who received surgical treatment. In most of the cases, the aortic orifice of the tunnel arose from or above the right coronary sinus, and the tunnel was located antero-laterally to the ascending aorta. However, our case demonstrated that the aortic orifice arose from the left coronary sinus and the tunnel lay postero-laterally to the ascending aorta. We could find only three reports in which the aortic orifice is opened from the left aortic sinus [5–7]. In this situation, incision of the tunnel is difficult and the tunnel should be closed through aortic incision.
As for the operative technique, Serino and colleagues [8] report that closing the aortic defect by direct suture distorts the cusps by pulling them toward the weak aortic wall, which remains unsupported within the dilated aortic sinus. From this point of view, the patch technique is believed to reduce that risk. Our case demonstrated a slit-like opening at the aortic end with no valve distortion. Then, primary closure of the aortic orifice was performed in addition to plication (obliteration) of the tunnel. The short-term result is satisfactory, but late development of severe aortic regurgitation remains a matter of concern [9]. Careful observation is needed in this anomaly after the surgical repair.
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References
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- Levy MJ, Lillehei CW, Anderson RC, Amplatz K, Edwards JE. Aortico-left ventricular tunnel. Circulation 1963;27:841–853.[Abstract/Free Full Text]
- Martins JD, Sherwood MC, Mayer JE Jr. Keane JF. Aortico-left ventricular tunnel 35-year experience. J Am Coll Cardiol 2004;44:446–450.[Abstract/Free Full Text]
- Levy MJ, Schachner A, Blieden LC. Aortico-left ventricular tunnel collective review. J Thorac Cardiovasc Surg 1982;84:102–109.[Abstract]
- Horvath P, Balaji S, Skovranek S, Hucin B, de Leval MR, Stark J. Surgical treatment of aortico-left ventricular tunnel. Eur J Cardiothorac Surg 1991;5:113–117.[Abstract]
- Grant P, Abrams LD, De Giovanni JV, Shah KJ, Silove ED. Aortico-left ventricular tunnel arising from the left aortic sinus. Am J Cardiol 1985;55:1657–1658.[CrossRef][Medline]
- Hucin B, Horvath P, Skovranek J, Reich O, Samanek M. Correction of aortico-left ventricular tunnel during the first day of life. Ann Thorac Surg 1989;47:254–256.[Abstract]
- Michielon G, Sorbara C, Casarotto DC. Repair of aortico-left ventricular tunnel originating from the left aortic sinus. Ann Thorac Surg 1998;65:1780–1783.[Abstract/Free Full Text]
- Serino W, Andrande JL, Ross D, de Lval MR, Somerville J. Aorto-left ventricular communication after closure later postoperative problems. Br Heart J 1983;49:501–506.[Abstract/Free Full Text]
- Honjo O, Ishino K, Kawada M, Ohtsuki S, Akagi T, Sano S. Late outcome after repair of aortico-left ventricular tunnel – 10-year follow-up. Circ J 2006;70:939–941.[CrossRef][Medline]
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Abstract
1. Introduction