Ann Thorac Surg 2006;82:1113-1115
© 2006 The Society of Thoracic Surgeons
Case report
Aorto-Left Ventricular Tunnel: An Alternative Surgical Approach
Fotios A. Mitropoulos, MD, PhDa,*,
Hillel Laks, MDb,
Meletios A. Kanakis, MDa,
Daniel Levi, MDb
a University of Athens, School of Medicine, Athens, Greece
b David Geffen School of Medicine at UCLA, Los Angeles, California
Accepted for publication December 20, 2005.
* Address correspondence to Dr Mitropoulos, University of Athens School of Medicine, Monastiriou 8, Thracomacedones, Athens, 13676 Greece (Email: fotiosmitropoulos{at}yahoo.com).
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Abstract
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A 10-day-old infant was diagnosed with aorto-left ventricular tunnel. An alternative surgical approach is described. This technique may minimize the risk of aortic valve injury.
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Introduction
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Aorto-left ventricular tunnel (ALVT) is a rare congenital paravalvar communication between the aorta and the left ventricle. It was first described in 1963 by Levy and colleagues [1]. We describe a new surgical approach to correct this malformation, which we believe has not been reported in the English literature so far. This technique may minimize the risk of aortic valve (AV) injury.
A 10-day-old twin boy, was born by a cesarean delivery after an uncomplicated full-term pregnancy. A persistent systolic murmur (1/6) was detected and a transthoracic echocardiogram showed a large ALVT. The aortic orifice was distal to the sinuses of Valsalva and the coronary ostia were not involved. The anterior leaflet of the mitral valve opened poorly, secondary to the jet created by the regurgitated blood flow from the ALVT. The left ventricle was mildy dilated with a fraction shortening of 30% and a mild aortic leaflet prolapse (right coronary cusp). There was also a patent ductus arteriosus. Catheterization confirmed the echocardiographic findings (Fig 1).
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Fig 1. Aorto-left ventricular tunnel (ALVT) as depicted from the lateral view on the cardiac angiogram. (A = ALVT; B = ascending aorta; C = right coronary artery.)
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After opening the pericardium, on the anterior aspect and leftwards of the aorta, there was a large tunnel emptying to the left ventricle below the AV (Fig 2). The ductus arteriosus was ligated. The patient was placed on cardiopulmonary bypass and after the heart was arrested, the ALVT was opened in a longitudinal fashion. Stay stitches were placed on either side to keep the tunnel open. The aortic opening of the tunnel appeared to be above the sinotubular junction. Pericardium treated with 6% glutaraldehyde was used to close the aortic orifice through the open tunnel. Then the ventricular orifice was patched with tanned pericardium through the open tunnel with extra care not to injure the AV (Figs 3A, B). The atrioseptal defect was also closed primarily and the patient was weaned from cardiopulmonary bypass without difficulty. The intraoperative transesophageal echocardiogram showed complete closure of the tunnel with no aortic valve regurgitation.
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Fig 2. Picture as seen from the surgeon's view after opening the pericardium. (A = pulmonary artery; B = aorto-left ventricular tunnel; C = aorta; D = right atrium; E = right ventricle.)
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Fig 3. (A) Schematic representation of the surgical anatomy. (Aa = ascending aorta; LAA = left atrial appendage; PA = pulmonary artery; RA = right atrium; SVC = superior vena cava.) (B) After the tunnel has been opened, the aortic and the ventricular orifices are seen through the tunnel. (A = aortic orifice; B = ventricular orifice; C = tunnel opened; D = aortic cannula; E = venous cannula.)
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Comment
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Aorto-left ventricular tunnel is often diagnosed in infancy, but in some patients it is recognized later. The ALVT can be considered a defect of the aortic root affecting the interleaflet triangle [2]. Diagnosis has been reported in utero [3]. Cases diagnosed in utero are more severe and have a worse outcome [3]. Hovaguimian and colleagues [4] proposed a classification of four anatomic types. They described a slit-like opening at the aortic end with no valve distortion in 24% of the cases (type 1), a large extracardiac aneurysm in 44% (type 2), intracardiac aneurysm of the septal portion of the tunnel, with or without right ventricular outflow tract obstruction in 24% (type 3), and a combination of types 2 and 3 in 8% (which is type 4). In our case, the ALVT belonged to type 2. Echocardiography can identify the ALVT, although some may recommend catheterization to separate the ALVT from AV regurgitation and to identify associated lesions [5]. Surgical closure has been recommended at the time of diagnosis, including asymptomatic patients, due to inadequacy of medical therapy, risk of developing severe aortic regurgitation, and the excellent surgical results [5]. The goal of any treatment modality is to obliterate the tunnel [3]. The techniques that have been described are summarized as follows: (1) closure of the aortic orifice of the tunnel with or without a patch (Dacron, pericardium, Teflon); (2) closure of the ventricular end of the tunnel; (3) obliteration of the tunnel (ie, ligation of the tunnel, or partial resection of the tunnel, or filling of the tunnel with gel-foam); and (4) closure of both orifices (aortic and ventricular) [4–6]. Surgical repair undoubtedly needs to be tailored for each case. Rarely, the coronary ostium may arise from the tunnel itself, and closure of the orifice of the tunnel would compromise the patency of the coronary artery. Horvath and colleagues [7] described excision and reimplantation of the coronary button before closing the aortic orifice. There is also a case of ALVT with severe aortic stenosis that was treated with replacement of the aortic root with an aortic homograft [8]. The closure of the aortic orifice is typically performed by opening the ascending aorta. There is a risk of AV injury, especially if trying to close the ventricular opening through this approach. Serino and colleagues [9] support 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. In that way, the aortic regurgitation may persist and progress even if repaired in infancy [9]. From this point of view, the patch technique is believed to reduce that risk. The goal is to close the communication by distorting the cusps as little as possible, reduce the size of the aneurysmal sinus and aortic root, and reinforce the aortic wall in the same region. This eliminates the risk of aortic regurgitation [9]. We believe that by using the direct approach through the tunnel and closing both ostia with pericardial patches avoids distortion of the AV while supporting the aortic wall, and this is easier to perform. In addition, the risk of injury to the AV leaflets while trying to close the ventricular end is minimized.
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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]
- Ho SY, Muriago M, Cook AC, Thiene G, Anderson RH. Surgical anatomy of aorto-left ventricular tunnel Ann Thorac Surg 1998;65:509-514.[Abstract/Free Full Text]
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- Hovaguimian H, Cobanoglu A, Starr A. Aortico–left ventricular tunnela clinical review and new surgical classification. Ann Thorac Surg 1988;45:106-112.[Abstract]
- Martins JD, Sherwood MC, Mayer JR JE, Keane JF. Aortico-left ventricular tunnel35-year experience. J Am Coll Cardiol 2004;44(2):446-450.[Abstract/Free Full Text]
- Levy MJ, Schachner A, Blieden LC. Aortico-left ventricular tunnelcollective 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]
- Weldner P, Dhillon R, Taylor JFN, de Leval MR. An alternative method for repair of aortico-left ventricular tunnel associated with severe aortic stenosis presenting in a newborn Eur J Cardiothorac Surg 1996;10:380-382.[Abstract]
- Serino W, Andrande JL, Ross D, de Leval MR, Somerville J. Aorto-left ventricular communication after closurelater postoperative problems. Br Heart J 1983;49:501-506.[Abstract/Free Full Text]
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Abstract
Introduction
