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Blackmer K, Shillingford M, Ferns S. Aorta to left ventricle tunnel presenting with cardiac failure in a neonate. BMJ Case Rep 2024; 17:e255497. [PMID: 38216156 PMCID: PMC10806979 DOI: 10.1136/bcr-2023-255497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024] Open
Abstract
We report an unusual case of an aorta to left ventricular communication in a neonate presenting with cardiac failure. Although extremely rare, this defect is the most common cause of abnormal blood flow from the aorta to a ventricle in infancy. Early diagnosis and prompt surgical repair are critical to management and results are generally excellent. Long-term follow-up is required to monitor for aortic insufficiency.
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Affiliation(s)
- Kara Blackmer
- Cardiac Surgery, Wolfson Children's Hospital, Jacksonville, Florida, USA
| | | | - Sunita Ferns
- Department of Pediatrics, University of Illinois College of Medicine in Peoria, Peoria, Illinois, USA
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Chowdhury UK, Anderson RH, George N, Singh S, Sankhyan LK, Pradeep D, Chauhan A, Sengupta S, Vaswani P. A Review of the Surgical Management of Aorto-ventricular Tunnels. World J Pediatr Congenit Heart Surg 2021; 12:103-115. [PMID: 33407031 DOI: 10.1177/2150135120954809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We present a synthesis of 95 published investigations of the exceedingly rare tunnels that can exist between the aortic root and the left or right ventricles. From the 220 suitable cases included in these investigations, we reviewed the clinical presentations, modalities used for diagnosis, surgical approaches, and outcomes. Diagnostic information was provided by clinical presentation, radiographic findings, saline contrast echocardiography, computed tomographic angiocardiography, magnetic resonance imaging, cardiac catheterization, and angiocardiography. These techniques elucidated the coronary arterial origins and associated defects and defined the disease before surgery. Patients occasionally present with an asymptomatic cardiac murmur and cardiomegaly, but most suffer cardiac failure in the first year of life when the tunnel enters the left ventricle. Antenatal diagnosis by fetal echocardiography is reliable after 18 weeks of gestation. Associated defects, involving the proximal coronary arteries or the aortic or pulmonary valves, are present in nearly half the cases. Prompt diagnosis and surgical repair are important for a favorable outcome. Overall, operative mortality has been cited to be between 3% and 8.3%. Associated congenital coronary arterial anomalies, residual severe aortic stenosis, poor left ventricular function, and rupture of an infected suture line have been the reported causes of death. Despite early surgical intervention, an incidence of 16% to 60% postoperative residual aortic regurgitation of varying severity has been reported. The requirement of further repair or replacement of the aortic valve ranges from 0% to 50%. We submit that an increased appreciation of these details relative to the tunnels will contribute to improved surgical management.
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Affiliation(s)
- Ujjwal Kumar Chowdhury
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Robert H Anderson
- Institute of Biomedical Sciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Niwin George
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Sukhjeet Singh
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Lakshmi Kumari Sankhyan
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Doniparthi Pradeep
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Abhinavsingh Chauhan
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Sanjoy Sengupta
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Prateek Vaswani
- Cardiothoracic Sciences Centre, 28730All India Institute of Medical Sciences, New Delhi, India
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Abstract
Aorto-ventricular tunnel is an extremely rare congenital heart defect, consisting of failure of attachment of an aortic leaflet along the semilunar hinge. In all published reports the leaflet involved was either the right coronary leaflet, most frequently, or the left coronary leaflet, in most of the cases opening toward the left ventricle, with only one-eighth of the reported cases communicating with the right ventricle. Treatment of the aorto-ventricular tunnel has been anecdotally reported by interventional closure with a device and more frequently with surgical approach, either as an isolated malformation or as associated lesions. To the best of our knowledge, the presence of an aorto-ventricular tunnel of the non-adjacent aortic leaflet in transposition of the great arteries has never been reported. We have observed an aorto-ventricular tunnel involving the non-adjacent leaflet of the aortic root, which after arterial switch became the pulmonary root. The patient presented 18 years after the arterial switch with progressive dilatation of the right ventricle due to severe degree of pulmonary valve regurgitation, confirmed by echocardiography and cardiac MRI. Indication for surgery was given with the plan for a pulmonary valve implantation. Because of the intra-operative finding of disconnection of the anterior leaflet of the pulmonary valve (former aortic valve) along the semilunar hinge, the surgical plan was modified and the anterior leaflet was attached to the valve annulus, with subsequent plasty in correspondence with the right and left commissurae to reduce the size of the dilated annulus to normal diameter. The post-operative course was uneventful, with extubation after few hours and discharge 4 days after surgery, with echocardiography showing trivial degree of pulmonary valve regurgitation. The patient remains in good conditions 6 months after surgery.
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Affiliation(s)
- Antonio F Corno
- Cardiovascular Research Center, University of Leicester, Leicester, United Kingdom.,East Midlands Congenital Heart Center, University Hospitals of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Saravanan Durairaj
- East Midlands Congenital Heart Center, University Hospitals of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Robert H Anderson
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne, United Kingdom
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Xie M, Yin J, Lv Q, Wang J. Clinical value of diagnosing aortico-left ventricular tunnel by echocardiography. Exp Ther Med 2016; 12:3315-3319. [PMID: 27882155 PMCID: PMC5103784 DOI: 10.3892/etm.2016.3747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 09/20/2016] [Indexed: 11/15/2022] Open
Abstract
In order to assess the clinical value of echocardiography in the diagnosis of aortico-left ventricular tunnel (ALVT) the echocardiographic data and clinical manifestations of six patients with ALVT were analyzed in the present study. Based on the results, a comprehensive study was conducted regarding 147 cases from related documents. Six patients were confirmed with ALVT by surgery. The echocardiographic images of the patients revealed an abnormal communication beginning in the ascending aorta above the coronary arteries, bypassing the aortic valve, and ending in the left ventricle. The color Doppler flow imaging showed a high-speed to- and -fro flow with or without the involvement of the aortic valve. According to Hovaguimian type casting, there were two cases of type I, two cases of type III, one case of type IV, and one case of type II (postoperative recanalization). Of the 153 cases reported, the accuracy rate of the ultrasound diagnosis was 79.6%, the misdiagnosis rate was 17.1%, and the missed diagnostic rate was 3.3%. In conclusion, echocardiography is the preferred method for non-invasive preoperative diagnosis of the ALVT and can accurately describe the type and involvement of the cardiac structure.
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Affiliation(s)
- Manying Xie
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Jiabao Yin
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Qing Lv
- Department of Ultrasound Imaging, Xiehe Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Jing Wang
- Department of Ultrasound Imaging, Xiehe Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
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Kathare P, Subramanyam RG, Dash TK, Muthuswamy KS, Raghu K, Koneti NR. Diagnosis and management of aorto-left ventricular tunnel. Ann Pediatr Cardiol 2015; 8:103-7. [PMID: 26085759 PMCID: PMC4453176 DOI: 10.4103/0974-2069.157021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Aorto-left ventricular tunnel (ALVT) is a rare congenital extracardiac channel with progressive left ventricular dilatation needs early correction. Materials and Methods: This is a report of diagnosis and management of aorto-left ventricular tunnel (ALVT) over a period of 11 years from a single institution. Seven patients (age range: 7 days-45 years) presented with heart failure. The diagnosis of ALVT was made by transthoracic echocardiogram in all cases. Results: Treatment was refused by two patients who died during follow-up. Surgical closure of the tunnel was done in four cases, of which one needed Bentall procedure. Two patients had residual leak after the surgery. Transcatheter closure using Amplatzer muscular device was performed in two cases (for postoperative residual leak in one and primary procedure in the other). Significant hemolysis developed in one of them, necessitating the removal of the device and closed surgically. This child underwent aortic valve replacement two years later. All the remaining patients were doing well during the median follow-up of 30 months (range: 1.5-9 years). Conclusion: ALVT is a rare and potentially fatal anomaly that is ideally managed surgically. Catheter closure has a limited role.
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Affiliation(s)
- Pallavi Kathare
- Department of Cardiac Surgery, Gutti, Consultant Pediatric Cardiologist, Care Hospital, Hyderabad, Telangana, India
| | | | - Tapan Kumar Dash
- Consultant Pediatric Cardiac Surgery, Care Hospital, Hyderabad, Telangana, India
| | | | - K Raghu
- Consultant Cardiologist, Care Hospital, Hyderabad, Telangana, India
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Zhu J, Jiang Z, Huang J, Wu S, Mei J. Aortico-left ventricular tunnel arising from the noncoronary sinus associated with a ventricular septal defect. Ann Thorac Surg 2014; 98:e135-7. [PMID: 25468125 DOI: 10.1016/j.athoracsur.2014.08.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 08/10/2014] [Accepted: 08/29/2014] [Indexed: 11/19/2022]
Abstract
Aortico-left ventricular tunnel is a very rare congenital heart disease. The aortic orifice of the tunnel usually situates in the right or left coronary sinus. Here we present the case of one child who had an unusual tunnel arising from the noncoronary sinus in addition to an unrestrictive perimembranous ventricular septal defect. Surgical repair was performed at 2 months of age and there was no postoperative residual lesion.
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Affiliation(s)
- Jiaquan Zhu
- Cardiothoracic Surgery Department, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Zhaolei Jiang
- Cardiothoracic Surgery Department, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Jianbing Huang
- Cardiothoracic Surgery Department, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Shubin Wu
- Cardiothoracic Surgery Department, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Ju Mei
- Cardiothoracic Surgery Department, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China.
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Pericardial single-patch repair of right coronary artery from aorto-left ventricular tunnel. Pediatr Cardiol 2010; 31:714-6. [PMID: 20151303 DOI: 10.1007/s00246-010-9655-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
Abstract
Aortico-left ventricular tunnel (ALVT) is a rare congenital paravalvar communication between the aorta and the left ventricle. This anomaly has been associated with the right coronary artery (RCA) arising directly from the tunnel. Surgical repair of this later condition is challenging and is usually undertaken by closure of the ventricular and aortic ends of the tunnel and transfer of the RCA. Regardless of the surgical technique, development of early and late aortic regurgitation (AR) remains a concern. We report a neonate with ALVT and the RCA coming off the tunnel that was successfully managed by closure of both ends of the tunnel, reinforcement of the annulus with autologous pericardium, and leaving the RCA perfused by way of the tunnel. After 6 months of follow-up, no AR has been shown on echocardiography.
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Abstract
Aorto-ventricular tunnel is a congenital, extracardiac channel which connects the ascending aorta above the sinutubular junction to the cavity of the left, or (less commonly) right ventricle. The exact incidence is unknown, estimates ranging from 0.5% of fetal cardiac malformations to less than 0.1% of congenitally malformed hearts in clinico-pathological series. Approximately 130 cases have been reported in the literature, about twice as many cases in males as in females. Associated defects, usually involving the proximal coronary arteries, or the aortic or pulmonary valves, are present in nearly half the cases. Occasional patients present with an asymptomatic heart murmur and cardiac enlargement, but most suffer heart failure in the first year of life. The etiology of aorto-ventricular tunnel is uncertain. It appears to result from a combination of maldevelopment of the cushions which give rise to the pulmonary and aortic roots, and abnormal separation of these structures. Echocardiography is the diagnostic investigation of choice. Antenatal diagnosis by fetal echocardiography is reliable after 18 weeks gestation. Aorto-ventricular tunnel must be distinguished from other lesions which cause rapid run-off of blood from the aorta and produce cardiac failure. Optimal management of symptomatic aorto-ventricular tunnel consists of diagnosis by echocardiography, complimented with cardiac catheterization as needed to elucidate coronary arterial origins or associated defects, and prompt surgical repair. Observation of the exceedingly rare, asymptomatic patient with a small tunnel may be justified by occasional spontaneous closure. All patients require life-long follow-up for recurrence of the tunnel, aortic valve incompetence, left ventricular function, and aneurysmal enlargement of the ascending aorta.
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Affiliation(s)
- Roxane McKay
- Division of Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, TN 38103, USA.
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Béïque F, De Tran QH, Ma F, Rudski L, Daves S, Angelini P. Anomalous right coronary artery originating from the left sinus of Valsalva. J Cardiothorac Vasc Anesth 2005; 18:788-98. [PMID: 15650996 DOI: 10.1053/j.jvca.2004.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- François Béïque
- Department of Anesthesia, SMBD Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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