Angiography of an Aneurysmal Aorto–Left Ventricular Tunnel
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).
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.