Circulation. 2007;116:e356-e358
doi: 10.1161/CIRCULATIONAHA.107.704387
(Circulation. 2007;116:e356-e358.)
© 2007 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Angiography of an Aneurysmal Aorto–Left Ventricular Tunnel
Ghassan Chehab, MD;
Jean Hayek, MD;
Zakhia Saliba, MD;
Issam El-Rassi, MD
From Saint-Joseph University (G.C., J.H., Z.S., I.E.-R.) and Lebanese University (G.C.), Beirut, Lebanon.
Reprint requests to Issam El-Rassi, Cardiac Surgery, Hotel-Dieu de France Hospital, PO Box 166-830, Naccache Blvd, Achrafieh, Beirut, Lebanon. E-mail issam.rassi{at}gmail.com
The aortoventricular tunnel is an abnormal congenital extracardiac communication between the ascending aorta and 1 of the ventricles.1 Approximately 130 cases have been reported in the literature, 90% being aorto–left ventricular tunnels (ALVTs).2 Echocardiography is the best diagnostic tool for ALVT, and thus cardiac catheterization is not routinely performed unless more information is needed concerning the coronary arteries. Coronary artery anomalies may be associated with ALVT in 45% of patients.3,4 The ostium of the right coronary artery may lie within the tunnel; alternatively, there may be complete absence of the origin of the left or right4 coronary ostium. In this report, we describe a rare angiographic appearance of an aneurysmal ALVT.
A 2-month-old boy was admitted to our institution with a suspected echocardiographic diagnosis of ALVT (Figure 1). Cardiac catheterization was performed to confirm diagnosis before surgery. It showed the ALVT developing as a large extracardiac aneurysm; the catheter was advanced from the femoral artery to the ascending aorta, then through the aortic opening of the tunnel just above the aortic valves; it looped completely in the extracardiac aneurysm (Figure 2A and 2B) and exited the tunnel through its left ventricular opening. The tunnel and the aneurysm were then injected with dye (Figure 3A and 3B).
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Figure 2. Angiography showing the catheter advanced through the tunnel down into the left ventricle. Arrows indicate the aortic entry and ventricular exit orifices of the tunnel. Ao indicates aorta; LV, left ventricle.
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Figure 3. Opacification of the tunnel. Arrows indicate right coronary artery (A) and left main coronary artery (B). Ao indicates aorta; LV, left ventricle; LMCA, left main coronary artery; and RCA, right coronary artery.
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In this case, the presence of separate left and right coronary ostia was confirmed on angiography (Figure 3). Surgical inspection revealed an aneurysmal 3-cm tunnel arising from the ascending aorta just above the right Valsalva sinus (Figure 4). The aortic orifice of the tunnel was situated 2 mm above the ostium of the right coronary artery. The ventricular orifice was situated under the right-left commissure of the aortic valve. Both orifices were closed separately with pledgetted interrupted stitches and 2 Gore-Tex patches from inside the opened aneurysmal tunnel. The postoperative course was uneventful, and the child was extubated 24 hours after surgery. Postoperative echocardiography confirmed the absence of any residual leak, with only mild aortic incompetence.
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Disclosures
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None.
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References
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1. Levy MN, Lillehei CW, Anderson RC, Amplatz K, Edwards JE. Aortico-ventricular tunnel.
Circulation. 1963; 27: 841–853.
[Abstract/Free Full Text]2. McKay R. Aorto-ventricular tunnel. Orphanet Encyclopedia. Paris, France; Orphanet–INSERM SC11; March 2005.
3. Hovaguimian H, Cobnoglu A, Starr A. Aortico-left ventricular tunnel: a clinical review and new surgical classification. Ann Thorac Surg. 1988; 45: 106–112.[Abstract]
4. Rauzier JM, Bonnet D, Zniber L, Sidi D, Aggoun Y, Acar P, Kachaner J, Vouhe P. Aortic-ventricular tunnel with right coronary atresia. Arch Mal Coeur Vaiss. 1997; 90: 725–727.[Medline]
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Circulation 2007 116: 1433.
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