Repair of aortico-left ventricular tunnel in the neonate: surgical, anatomic and echocardiographic considerations

Aorta to left ventricle tunnel presenting with cardiac failure in a neonate

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.

Surgical repair of an aortico-left ventricular tunnel with Takayasu's arteritis

Aortico-left ventricular tunnel is a very rare congenital cardiac anomaly, always arises from the right coronary sinus and enters the left ventricle. However, aortico-left ventricular tunnel associated with Takayasu's arteritis has not been described so far in the literature. Here, we present an unusual case of aortico-left ventricular tunnel associated with Takayasu's arteritis in a 44-year-old man.

A Review of the Surgical Management of Aorto-ventricular Tunnels

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.

Aorto-Right Ventricular Tunnel in Transposition of the Great Arteries

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.

Percutaneous device closure of aortico-left ventricular tunnel using Amplatzer vascular plug III

Aortico-left ventricular tunnel is a rare congenital heart defect. Reports on successful device closure of these defects are scarce. We are reporting the first case of device closure of aortico-left ventricular tunnel using an Amplatzer vascular plug III.

Aorto-left ventricular tunnel: uncommon site of origin and management

Cases of aorto-ventricular tunnel involving the right ventricle and more commonly, the left ventricle have been described. The site of origin is located above the right coronary cusp and occasionally, the left. We describe an aorto-left ventricular tunnel in a 16-year-old girl, with aneurysmal expansion into the right ventricular outflow tract. Its aortic origin was above the commissure of the right and noncoronary cusps of the aortic valve.

Aorto-ventricular tunnel

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.

Surgical correction of aortico-left ventricular tunnel

Aortico-left ventricular tunnel is a rare, paravalvular communication of unclear etiology between the ascending aorta and the left ventricle. The resultant regurgitant diastolic blood flow leads to varying degrees of volume overload and congestive heart failure. Diagnosis is typically made postnatally with echocardiography. Surgical correction is the treatment of choice consisting of either patch closure or primary repair of the aortic orifice. Prognosis is good, although a significant percentage of patients will eventually require valve replacement because of progressive aortic valvular insufficiency.

Aortico–left ventricular tunnel: 35-year experience

OBJECTIVES

The purpose of this study was to review our 35 years of experience with aortico-left ventricular tunnel (ALVT), with emphasis on diagnosis, surgical details, and follow-up.

BACKGROUND

Aortico-left ventricular tunnel is a rare congenital anomaly. Neonatal surgery has been advocated in all due to long-term concern of valvar aortic regurgitation (AR).

METHODS

We identified 11 patients from 1963 to August 2002. Clinical, echocardiographic, catheterization, and surgical details were reviewed.

RESULTS

Eight of 11 patients presented at less than six months old (six with congestive heart failure) and three later with a murmur, all with clinical evidence of AR. Associated lesions, most commonly aortic valve and coronary artery anomalies, were present in 45%. Catheter occlusion was considered but not performed in five. Spontaneous occlusion was documented in one. Ten had surgery (nine in our institution), seven with direct suture and two by patch closure of the aortic end of the AVLT. At follow-up (median, 5 years; 1 month to 35 years), all were asymptomatic; three had residual ALVT (one moderate, two small/trivial), with at most mild AR.

CONCLUSIONS

Aortico-left ventricular tunnel is a rare cardiac malformation with a good post-operative long-term outcome. Associated lesions occurred in 45%. Catheterization should be reserved for patients with unclear non-invasive findings or transcatheter closure. We recommend surgery for most patients. We report spontaneous closure in one patient, prompting consideration of conservative follow-up in rare small, asymptomatic AVLT.

Successful repair of aortico-left ventricular tunnel associated with severe aortic stenosis in a newborn

A one-day-old infant presented with severe congestive heart failure and a continuous precordial murmur. Noninvasive studies revealed an aortico-left ventricular tunnel and severe valvar aortic stenosis. Angiocardiography confirmed the diagnosis. Patch closure of the tunnel and aortic valvotomy were accomplished successfully at 24 h of age.

Successful two patch repair of the aortico-left ventricular tunnel

A 7-month-old boy with aortico-left ventricular tunnel arising from the right coronary sinus underwent surgical correction using the two patch technique. The diagnosis was confirmed by 2D and Doppler echocardiogram alone. Patch closure of both the aortic and ventricular ends of the tunnel is recommended in order to prevent postoperative aortic regurgitation and recurrence of the lesion.

Prenatal diagnosis of an aortico-left ventricular tunnel

Aortico-left ventricular tunnel is a rare abnormal communication between the ascending aorta and the left ventricle. Early diagnosis and prompt surgical repair prevent congestive heart failure or consecutive valvular insufficiency. However, in utero diagnosis of this heart malformation has been rarely described and none of those children survived. We report on a case of aortico-left ventricular tunnel detected at 32 weeks' gestation with a favourable outcome after surgical repair at three months of age.

Congenital Heart Surgery Nomenclature and Database Project: aortico-left ventricular tunnel

The extant nomenclature for aortico-left ventricular tunnel is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. Efforts were made to include all relevant nomenclature categories using synonyms where appropriate. The Hovaguimian classification appears most useful to surgeons: type 1, a simple tunnel with a slit-like opening at the aortic end, no aortic valve distortion; type II, a large extracardiac aortic wall aneurysm of the tunnel with an oval opening at the aortic end, with or without ventricular distortion; type III, intracardiac aneurysm of the septal portion of the tunnel, with or without right ventricular outflow tract obstruction; and type IV, a combination of type II and III. A comprehensive database set is presented, which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail, which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Repair of aortico-left ventricular tunnel originating from the left aortic sinus

We report on a case of an 11-year-old asymptomatic child with aortico-left ventricular tunnel arising from the left aortic sinus. Preoperative transesophageal echocardiography showed a dilated aortic root with mild aortic valve incompetence and demonstrated the course of the tunnel, which originated from the left coronary sinus entering the outlet portion of the left ventricular outflow tract. Patch closure of the aortic end of the tunnel eliminated left ventricular volume overload with immediate marked reduction of cardiomegaly. At 10-month follow-up the child is asymptomatic and receiving no oral medications. Control two-dimensional Doppler echocardiography shows trivial central aortic valve incompetence.

Surgical anatomy of aorto-left ventricular tunnel

BACKGROUND

Owing to the rarity of aorto-left ventricular tunnel, surgical experience with this condition is generally limited. The anatomic configuration remains to be clarified in the light of better understanding of the normal aortic root.

METHODS

Two autopsied hearts with aorto-left ventricular tunnel were examined and compared with four normal heart specimens. The normal hearts were sectioned in a variety of planes to display the ventriculoarterial junction.

RESULTS

The leaflets of the pulmonary valve in both normal and abnormal hearts have semilunar attachments to a sleeve of freestanding ventricular musculature, the infundibulum. An extensive fibrofatty tissue plane then interposes between the freestanding infundibulum and the aortic sinuses. The aorto-left ventricular tunnels in the abnormal hearts pass within this tissue plane. The aortic orifice of the tunnel is distal to the level of the sinutubular junction, whereas the ventricular orifice is located within the interleaflet triangle between the right and left aortic sinuses.

CONCLUSIONS

Aorto-left ventricular tunnels bypass the normal ventriculoarterial junction but do not penetrate the septal musculature. This has implications for the fine-tuning of surgical repair.

Aortico-left ventricular tunnel in fetuses and infants

BACKGROUND

Aortico-left ventricular tunnel is a rare congenital abnormal communication between the aorta and the left ventricle presenting in early childhood as aortic regurgitation and cardiac failure. This condition has rarely been reported in fetuses. Operation is the only treatment, and postoperative aortic incompetence could be related to the age or the type of repair.

METHODS

We conducted a retrospective, two-institution review, from 1983 to 1995, of aortico-left ventricular tunnel diagnosed in utero and before 6 months of age.

RESULTS

Three cases of aortico-left ventricular tunnel were diagnosed in utero by Doppler echocardiography between 22 and 24 weeks' gestation. Prenatal aortico-left ventricular tunnel was associated with severe left ventricular dysfunction, aortic valve anomalies, and fetal hydrops. One death occurred in utero and one immediately after birth, and in 1 case pregnancy was interrupted. In these 3 cases the diagnosis was confirmed by autopsy. Three neonates and 2 infants had the diagnosis of aortico-left ventricular tunnel made after birth and underwent successful surgical repair. At short and midterm follow-up all patients are alive and aortic valve regurgitation is absent or trivial.

CONCLUSIONS

This series shows that aortico-left ventricular tunnel covers an anatomic spectrum of lesions. Cases diagnosed in utero by Doppler echocardiography are characterized by severe ventricular dysfunction, associated aortic valve lesions, and poor outcome. Postnatal cases represent the more favorable end of the spectrum, with no associated lesions, and can be repaired without mortality and with good functional results.

Echocardiographic-anatomical correlations in aorto-left ventricular tunnel

OBJECTIVE

To investigate the echocardiographic, morphological, and histological appearances of aorto-left ventricular tunnel observed in four fetal hearts and compare the findings with those reported in older patients with the malformation.

BACKGROUND

Previous studies have concentrated on clinical features of the malformation from birth to adult life and have speculated on either its embryological formation or its acquisition during late intrauterine life. The presentation of a large series of cases in fetal life is a unique opportunity to study the malformation at an early stage in its natural course.

METHODS

A retrospective study was performed of four cases of aorto-left ventricular tunnel discovered among 872 cases of congenital abnormalities diagnosed at a tertiary centre for fetal echocardiography. Detailed echocardiographic and anatomical observations were made of the malformation as identified during fetal life. The precise anatomical arrangement was determined and compared with previous descriptions found in journals published in English.

RESULTS

In fetal life, as after birth, the malformation is characterised by enlargement and hypertrophy of the left ventricle, enlargement of the aortic root, and free regurgitation at the level of the aortic valve. Anatomical abnormalities are found at the aortic ventriculoarterial and sinutubular junctions as well as in the intervening aortic wall. These are unrelated to necrosis, ischaemia, or the presence of mucopolysaccharides.

CONCLUSIONS

The lesion is a developmental abnormality that should be reliably diagnosed by fetal echocardiography combined with colour flow Doppler echocardiography during the mid-trimester. The exact anatomical relations clarified by this study are pertinent to diagnosis and subsequent surgical correction.

Role of transesophageal echocardiography in the management of aortic-left ventricular tunnel

A 10-year-old patient has been followed for 10 years after repair of an aortic-left ventricular tunnel (ALVT) for residual aortic regurgitation and significant recurrent leak through the ALVT. Transesophageal echocardiography (TEE) was done prior to surgery and intraoperatively to (1) clarify the precise anatomy of the ALVT, (2) evaluate the degree of aortic regurgitation, and (3) assess the repair. Delineation of the anatomy of the ALVT and assessment of the residual aortic insufficiency helped with the intraoperative decision-making. We describe the TEE findings of a residual ALVT in this patient and discuss the role of TEE in managing the lesion.

Surgical repair of aorto-right ventricular tunnel in an infant

A rare case of aorta to right ventricle tunnel with associated pulmonary stenosis was corrected on cardiopulmonary bypass in a 3-month-old infant. Both the aortic and ventricular openings were closed with a patch. Although the repair was successful and the child was discharged from the hospital, septicemia developed and she died later. Early repair of this defect is recommended.

Aortico-left ventricular tunnel associated with critical aortic stenosis in the newborn

Aortico-left ventricular tunnel is a rare congenital malformation. A unique case of critical aortic stenosis in a neonate accompanying aortico-left ventricular tunnel is described. Successful surgical correction was performed without invasive studies following echocardiographic recognition of the defect.

Aortico-left ventricular tunnel: long-term outcome after surgical repair

Over a 14 year period, four children (three male, one female) underwent surgical correction of an aortico-left ventricular tunnel. All presented in infancy (age range 5 days to 9 months). The presenting feature was a systolic and diastolic murmur in all, one of whom developed heart failure within 2 weeks of presentation. In the first two patients, the echocardiographic findings were inconclusive and the diagnosis was confirmed at cardiac catheterization (at 10 and 23 months of age, respectively); the other two were diagnosed echocardiographically by two-dimensional and Doppler color flow imaging. All four patients underwent surgery by patch closure of the aortic end of the tunnel (three patients) or direct suture closure (one patient) and there were no deaths. The mean age at operation was 11 months. During a mean follow-up period of 71 months (range 2 to 157), three patients have clinical and echocardiographic evidence of trivial aortic valve regurgitation, which was noted in the immediate postoperative period in one and at early (less than 6 months) follow-up study in the other two. All are symptom-free, are taking no medications and are growing and developing normally. Aortico-left ventricular tunnel can be accurately diagnosed by echocardiography. In patients presenting in infancy, echocardiography also provides the necessary morphologic information to enable surgical correction without angiography. Early operation is associated with an excellent outcome, whereas repair at a later age is associated with a high incidence of residual aortic regurgitation requiring further surgery.

Correction of aortico-left ventricular tunnel during the first day of life

Two critically ill newborns with aortico-left ventricular tunnel and severe heart failure were operated on at six and 14 hours after birth. The diagnosis was established clinically by the auscultatory finding of systolic and diastolic murmurs and by two-dimensional and Doppler echocardiography. In the first newborn, the left aortic sinus was connected with the left ventricle below the aortic valve by an aneurysmatically dilated tunnel. In the second patient, the tunnel connected the right aortic sinus and the left ventricle. The repair was performed under deep hypothermia, total hemodilution, and cardiopulmonary bypass. The tunnel was closed with two patches of Gore-Tex on the aortic and ventricular orifices. Both children are free from symptoms and are developing normally 10 and 8 months after repair.

Aortico-left ventricular tunnel: a clinical review and new surgical classification

This is a collective review of aortico-left ventricular tunnel (ALVT) in the English-language literature. We include the long-term follow-up of a previously reported patient, and a report on 2 new patients. To date, 37 cases of ALVT have been reported. Controversies regarding the definition, etiology, local anatomy, and treatment are discussed. The ages of the patients ranged from 1 day to 25 years old, and the male to female ratio was 2:1. There were associated anomalies in 27% of the patients, and moderate to severe heart failure in 59% of them. Mortality was 100% in the medically managed group; the surgical mortality was 16%. Previous surgical techniques utilized were simple closure, patch closure of the aortic end, and obliteration of the tunnel on both ends. Progressive aortic incompetence seems to be a common, but not well-documented problem on long-term follow-up. We have classified the lesion into four types (I, II, III, and IV) that have a bearing on the appropriate surgical techniques of repair, and describe a new technique for the repair of type III ALVT in which septal aneurysm is present.

Surgical repair of aortico-left ventricular tunnel (ALVT)

ALVT is a very rare congenital malformation. Until 1983 a collective review reported only 37 cases published. A 5-month-old girl with a body weight of 5.5 kg was referred for cardiomegaly and cardiac murmur. 2D-echo revealed the diagnosis which was later confirmed by angiography. The child was then operated upon with extracorporeal circulation using deep hypothermia (20 degrees C). The aortic orifice of the tunnel was closed with 3 pledget reinforced sutures. Cross-clamp time was 17 min. Electromagnetic flowmetry suggested an insufficiency of 78% preoperatively, and postoperatively this was reduced to 6%. Angiography was performed two weeks postoperatively, revealing mild valvular aortic insufficiency. She was discharged from the hospital 15 days postoperatively. ALVT should be corrected surgically as soon as the diagnosis is made.

Sinus of Valsalva aneurysm complicating bacterial endocarditis in an infant: diagnosis with two-dimensional and Doppler echocardiography

Sinus of Valsalva aneurysm is a rare complication of bacterial endocarditis in infancy and childhood. This report describes an infant with congenital aortic stenosis who developed bacterial endocarditis after abdominal surgery and placement of indwelling central venous catheters for long-term parenteral nutrition. Bacterial endocarditis in this infant was complicated by the development of an aneurysm of the left sinus of Valsalva. Surgical intervention was necessary because of gradual expansion of the aneurysm with compression of the adjacent right pulmonary artery and descending aorta. Two-dimensional and Doppler echocardiography proved useful for the initial diagnosis and serial follow-up of this unusual disorder and for its successful surgical management.

Aortico-left ventricular tunnel: diagnosis based on two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging

Aortico-left ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. In previously reported cases, the diagnosis has often been missed initially despite use of cardiac catheterization and angiography. We describe a patient who underwent successful surgical correction of this malformation at 10 months of age after the diagnosis had been established by use of two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging. Aortico-left ventricular tunnel can be diagnosed by use of these noninvasive means without cardiac catheterization.

Management of aortic left ventricular tunnel

A 22 year old man had a diagnosis of left ventricular aortic tunnel established during infancy. Surgical repair was deferred at that time because his severe aortic root deformity would also have required aortic valve replacement. His current lack of symptoms together with a normal exercise capacity could be used as an argument against routine early surgical repair of the tunnel, particularly when the possible need for additional aortic valve replacement is considered.

Pulsed Doppler and two-dimensional echocardiographic findings in aortico-left ventricular tunnel

Two-dimensional echocardiography was used to make the anatomic diagnosis of aortico-left ventricular tunnel in a 1 day old infant. Pulsed Doppler echocardiography allowed directional flow to be determined within the tunnel. The findings were confirmed by cardiac catheterization and by direct visualization at the time of surgical repair. Aortic valve insufficiency was excluded before and after surgery using pulsed Doppler echocardiography. The anatomy and physiology of aortico-left ventricular tunnel can thus be documented using noninvasive techniques.