Aorto-Left Ventricular Tunnel Neonatal Repair
Introduction.
Levy et al [1] first described the aorto-left ventricular tunnel in 1963. This
rare congenital malformation is an abnormal channel that connects the ascending
aorta with the left ventricle bypassing the aortic valve. In view of its
rarity, surgical series are small. Most of the patients develop symptoms of
heart failure during the first year of life but there are cases of asymptomatic
adults [2-3]. Onset of heart failure depends on the cross-sectional area of
tunnel and the amount of aortic regurgitation. We describe the surgical
approach in a neonatal patient.
Case report
The patient was a two-day-old, three-kilogram male, with prenatal diagnosis of
aorto-left ventricular tunnel. From birth he presented a situation of heart
failure requiring CPAP and inotropes. The echocardiogram showed an aorto-left
ventricular tunnel in the right Valsalva sinus of 5mm and an aortic annulus of
8mm. The aortic valve was dysplastic and thickened. The left ventricular
function was normal.
Operation Technique and Result
We performed a median sternotomy. There was a big aneurysm of the right
Valsalva sinus. Bicaval cannulation was established. A vent was placed in the
right superior pulmonary vein. Mild hypothermia at 28° was reached. The aorta
was clamped and anterograde cardioplegia with external occlusion of the tunnel
was infused. The aorta was incised transversely just above the sinotubular
junction. Extra cardioplegia was delivered to right coronary artery. An
enlargement of the aortotomy was made in the aneurysmal sinus. An equine patch
was used to close the ventricular opening of the tunnel with running
polypropylene suture. The ventricular aneurysm was excluded. The patch was
anchored to the aortic annulus. A second equine patch was used to close the
aortic opening of the tunnel in a T-shape orientation. Removal of the
aneurysmal tissue from the aortic wall was accomplished and the aortic root was
close with a running polypropylene suture. A second-layer suture was performed
to ensure good hemostasis. The aortotomy was closed with running suture. A right
atriotomy was made in order to close the atrial septal defect. An equine patch
was used with running suture. The right atriotomy was closed.
The postoperative echocardiogram showed no residual leak of the tunnel closure and
there was no significant gradient or regurgitation of the aortic valve.
The chest was left open until third postoperative day. The patient was
extubated and inotropes were withdrawn 9 days and 13 days after surgery,
respectively. The ICU stay was 18 days. The postoperative course was
uneventful. The patient was discharged home on postoperative day 28. The
echocardiogram at 6 months of follow up remained without residual leak and with
mild aortic valve regurgitation without significant gradient.
References
1. Levy MJ, Lillehei CW, Anderson RC, Amplatz K, Edwards JE.
Aortico-left ventricular tunnel. Circulation. 1963;27:841-853.
2. Kafka H, Chan KL, Leach AJ. Asymptomatic aortico-left ventricular tunnel in
adulthood. Am J Cardiol. 1989;63(13):1021-1022.
doi:10.1016/0002-9149(89)90168-9
3. Mueller C, Dave H, Prêtre R. Surgical repair of aorto-ventricular tunnel.
Multimed Man Cardiothorac Surg. 2012;2012:mms006. doi:10.1093/mmcts/mms006
