Diagnosis and management of aorto-left ventricular tunnel

Diagnosis of an aortico-left ventricular tunnel in a fetus: a case report

An aortico-left ventricular tunnel is a rare congenital heart disease, and its prenatal diagnosis is even rarer. This report describes a fetus diagnosed with an aortico-left ventricular tunnel at 26 weeks of gestation. After delivery, the infant exhibited cyanosis and cessation of breathing. After resuscitation, he was transferred to the neonatal intensive care unit. Echocardiography confirmed an aortico-left ventricular tunnel. The infant survived after surgical repair. An aortico-left ventricular tunnel can be diagnosed by antenatal ultrasound, and prompt neonatal management can help to prevent perinatal morbidity and mortality.

Evolution in the management of aorta to left ventricular tunnel in a national congenital cardiology centre

An aorto-ventricular tunnel is a rare congenital cardiac defect, where a channel connects the lumen of the ascending aorta to the left or right ventricle. Four patients presented with an aorto-left ventricular tunnel over two decades at a median age of 8 months (range 0.1-10 months). Two patients (50%) had associated cardiac anomalies including hypoplastic left heart syndrome and left ventricular noncompaction/hypertrophic cardiomyopathy with aortic/pulmonary valve dysplasia in one patient each. Although traditionally surgical treatment has addressed this problem, management has evolved to transcatheter closure with excellent outcomes in appropriately selected patients at our national centre.

Aorto-Left Ventricular Tunnel - Prenatal Diagnosis and Outcome

PURPOSE

 Aorto-left ventricular tunnel (ALVT) is an extremely rare, albeit prenatally detectable, extracardiac channel that connects the ascending aorta to the cavity of the left ventricle.

MATERIALS AND METHODS

 All ALVTs diagnosed prenatally (2006-2020) in five tertiary referral centers were retrospectively assessed for prenatal ultrasound findings, intrauterine course, postnatal outcome, and surgical treatment. We focused on the size of the tunnel and alterations of perfusion of the left ventricular outflow tract and aortic arch.

RESULTS

 11 fetuses were diagnosed with ALVT at a mean gestational age of 24.8 weeks. All cases were associated with severe dilatation of the left ventricle and a to-and-fro flow in the left outflow tract. Signs of congestive heart failure were present in five fetuses, four of which were terminated and one of which died in the neonatal period. One fetus died in utero at 34 weeks without prior signs of cardiac failure. Of the five survivors, two underwent the Ross procedure. In both cases the prenatal left ventricular outflow was exclusively via a large tunnel. The remaining three neonates underwent patch closure of the tunnel. In these cases, the prenatal outflow of the left ventricle was via the aortic valve and simultaneously over the tunnel.

CONCLUSION

 Prenatal diagnosis of ALVT should be considered in the presence of left ventricular hypertrophy, dilatation of the aortic root, and to-and-fro flow in the aortic outflow tract. Signs of heart failure are associated with an unfavorable outcome. Large tunnels, particularly in combination with the absence of flow over the aortic valve, may be an unfavorable predictor of surgical repair.

Echocardiographic diagnosis of aorto-left ventricular tunnel with supravalvular pulmonic stenosis in a Shih-tzu dog

Background

The aorto-left ventricular tunnel (ALVT) is a congenital extracardiac channel that connects the ascending aorta to the left ventricle.

Case Description

A 2-year-old Shih-tzu dog presented with mild exercise intolerance. Echocardiography revealed an abnormal slit-like tunnel structure connecting the ascending aorta to the left ventricle, with diastolic blood flow from the aorta to the left ventricle. Echogenic membranous stenosis was observed in the main pulmonary artery. Based on these findings, the dog was diagnosed with ALVT and type I supravalvular pulmonic stenosis.

Conclusion

This is the first case report of ALVT in veterinary medicine that describes diagnostic imaging findings. ALVT should be considered in dogs with an aortic regurgitation murmur and can be detected by echocardiography.

Successful percutaneous closure of a recurrent aorto-left ventricular tunnel with an Amplatzer Vascular Plug II

Aorto-left ventricular tunnel is an extremely rare CHD clinically impressing as aortic regurgitation. This is usually corrected surgically, sometimes by percutaneous catheter intervention. Recurrent aorto-left ventricular tunnel has been reported occasionally. Reports of percutaneous closure of such recurrent aorto-left ventricular tunnels are rare. We hereby describe successful closure of a recurrent aorto-left ventricular tunnel with an Amplatzer Vascular Plug II.

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.

Aorta-cameral fistulas: Spectrum of CT findings and review

Aorto-cameral fistula (ACF) is an uncommon entity, defined as an abnormal communication between the aorta and a cardiac chamber. The most common causes include ruptured sinus of Valsalva aneurysm, infective endocarditis, traumatic injury, aortic dissection, or rarely can be iatrogenic in nature. While smaller communications may initially be asymptomatic, the natural course of these connections is generally refractory heart failure as they do not spontaneously heal. Larger fistulas can be life threatening with high mortality rates, and therefore once recognized, surgery is generally considered the treatment of choice. Diagnosis, however, can be challenging, and various imaging modalities are often used for diagnosis. This review highlights common underlying etiologies, clinical manifestations, and radiologic imaging appearances of ACF to each of the cardiac chambers of this uncommon, but clinically important entity, with emphasis on CT.

Characteristics and long-term outcomes of aortico-left ventricular tunnel

OBJECTIVES

Aortico-left ventricular tunnel (ALVT) is an extremely rare, abnormal paravalvular communication between the aorta and the left ventricle. Few studies have identified the characteristics and long-term prognosis associated with ALVT.

METHODS

The data of 31 patients with ALVT from July 2002 to December 2019 were reviewed. Echocardiography was performed in all patients during the follow-up period.

RESULTS

The median age of the patients was 11.5 years. Bicuspid aortic valve and dilatation of the ascending aorta were found in 13 patients, respectively. The aortic orifice in 20 patients showed a close relation to the right sinus and the right-left commissure. Of the 31 patients, 26 were operated on. Mechanical valve replacement was performed in 4 patients and aortic valve repair, in 6 patients. Ascending aortoplasty was performed in 5 patients and aortic replacement was done in 2 patients. One patient died of ventricular fibrillation before the operation. Follow-up of the remaining 30 patients ranged from 1 to 210 months (median 64 months). There were 4 deaths during the follow-up period: 1 had mechanical valve replacement and 3 did not undergo surgical repair. In the 26 patients without aortic valve replacement, 6 had severe regurgitation and 2 had moderate regurgitation. In the 28 patients without replacement of the ascending aorta, 11 had continued dilatation of the ascending aorta, including those who had aortoplasty.

CONCLUSIONS

The aortic orifice of ALVT showed an association with the right sinus and the right-left commissure. For patients who did not have surgery, the long-term survival rate remained terrible. Surgical closure should be done as soon as possible after ALVT is diagnosed. The main long-term complications after surgical repair included aortic regurgitation and ascending aortic dilatation.

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-left ventricular tunnel: case series of a rare disease

INTRODUCTION

Aorto-left ventricular tunnel is a rare disease that can cause significant morbidity early in life due to volume overload and left ventricular failure. Surgical intervention is usually curative with minimal early complications. However, long-term effects and outcome are not fully determined.

OBJECTIVE

We are reporting a case series of this rare CHD with its long-term outcome.

METHODS

We conducted a retrospective analysis of all children from birth to 14 years of age who were admitted between 2001 and 2020 with the diagnosis of aorto-left ventricular tunnel. Demographic, echocardiographic, and perioperative data were collected and reviewed. The pre-operative data were compared with data reviewed on the last outpatient follow-up.

RESULTS

Total of five patients fulfilled our inclusion criteria. Three patients were diagnosed after auscultating an incidental murmur, one had symptoms of congestive heart failure, and one had an abnormal fetal echocardiogram. Echocardiography demonstrated stenotic and regurgitant aortic valve with severely depressed left ventricle function in two patients, one of them with also single left coronary artery. The other three patients had normal aortic valve structure and normal ventricular function. All five patients had surgical repair, two by patch closure at aortic end of aorto-left ventricular tunnel, two by patch closure at both aortic and left ventricular ends, and one by aortic root replacement using a homograft. During follow-up, there was no residual aorto-left ventricular tunnel in any of our five cases, two had moderate aortic regurgitation and one had moderate residual aortic stenosis.

CONCLUSIONS

Spectrum of presentation for aorto-left ventricular tunnel varies from an occult lesion to frank left heart failure due to volume or less commonly, pressure overload. Early surgical repair is recommended and is usually associated with complete resolution. Long-term follow-up is recommended for aortic root dilatation and aortic valve competency, as valve function need to be addressed in a timely manner to avoid further complications.

Aorto-left ventricular tunnel - A case report

Aorto-left ventricular tunnel (ALVT) is a rare congenital anomaly with extracardiac channel connecting ascending aorta to the ventricle. It presents early in life due to congestive cardiac failure. We present a case of ALVT with unusual morphology in an 11-year-old male child with palpitations and dyspnea. We also describe the transesophageal echocardiography evaluation of ALVT.

Large right ventricular sinusoids in an infant with aorta-left ventricular tunnel and proximal right coronary artery atresia

We report a 1-month-old infant diagnosed with an aorta-left ventricular tunnel, ventricular septal defect, and right coronary atresia with right ventricular sinusoids. The patient's anatomy and physiology did not indicate right-ventricular-dependent coronary circulation, and therefore right ventricular decompression could be performed without compromising coronary perfusion during surgical correction. A detailed understanding of the coronary anatomy is critical in managing this defect when coronary anomalies are present.

Aorto-left ventricular tunnel with anomalous origin of right coronary artery and bicuspid aortic valve: a case report

Background

Aorto-left ventricular tunnel (ALVT) is a rare congenital extracardiac channel that connects the ascending aorta to the left ventricle. To our knowledge, no case has been thus far reported as ALVT with both anomalous origin of right coronary artery (AORCA) and bicuspid aortic valve (BAV).

Case presentation

We reported a case of a 5-year-old female diagnosed as ALVT with accompanying AORCA and BAV which had been previously misdiagnosed as aortic regurgitation (AR) triggered by BAV. Additionally, a special modality of ALVT was confirmed in this case during the surgery in which the tunnel was formed by the separation between the roots of two aortic leaflets during the diastolic period.

Conclusions

ALVT with both AORCA and BAV is clinically uncommon and the aberrant tunnel in ALVT can be formed by the gap between the roots of two aortic leaflets. Besides, ALVT with BAV might easily lead to an inaccurate diagnose as aortic regurgitation caused by BAV. Cardiac surgeons should be alerted for differential diagnosis of ALVT with BAV and isolated bicuspid aortic valve (BAV) causing aortic regurgitation (AR).

Aorto-left ventricular tunnel: a rare cause of heart failure in the newborn

Aorto-left ventricular tunnel is a rare congenital cardiac anomaly, consisting of a short abnormal pathway, usually from a sinus of Valsalva into the left ventricular cavity. It is usually diagnosed with echocardiography. We report a case of a newborn presenting with heart murmur and rapid progression to heart failure and left ventricular enlargement due to an aorto-left ventricular tunnel. Despite successful closure of the tunnel, the patient required a Ross procedure due to progressive aortic disease.

Congenital Aortico-Left Ventricular Tunnel: A Case Report of a Rare Cause of Aortic Regurgitation in Adults

The aortico-left ventricular tunnel is a rare congenital abnormality resulting in a pathologic connection between the aorta and the left ventricle. It often presents during infancy or early childhood as a cardiac failure symptom or an incidental finding of a cardiac murmur due to severe aortic regurgitation. It is, however, also occasionally found in asymptomatic adults. We describe a 20-year-old female presenting with palpitations in whom clinical evaluations with echocardiography and computed tomography angiography led to the diagnosis of severe aortic regurgitation caused by a tunnel connecting the right sinus of the aorta to the left ventricle. The patient underwent successful obstruction of the tunnel with an autologous pericardial patch and the repair of the dilated aortic root via the reduction aortoplasty technique. She was discharged on the 5th postoperative day with no complications. At 1 month's follow-up, she remained asymptomatic and echocardiography showed aortic valve competence with no residual regurgitation.

Transcatheter closure of a residual aorto-left ventricular tunnel: report of a case with a 6-year follow-up

Aorto-left ventricular tunnel is an exceedingly rare congenital cardiac defect. Early surgical closure is the treatment of choice. Residual or recurrent tunnel and aortic valve insufficiency are well-recognised complications after surgical repair. In this article, we report on successful transcatheter closure of a residual aorto-left ventricular tunnel using an Amplatzer duct occluder in a 7-year-old boy. The outcome after 6 years of follow-up is encouraging.