Sir,Aorto-left ventricular tunnel is a congenital connection between ascending aorta and left ventricle. It is one of the rarest conditions with an estimated incidence of 0.001% of all cardiac malformations.[1] Clinical spectrum is varied; at one end of the spectrum, they can be asymptomatic, while at the other end, they can have congestive cardiac failure and aortic regurgitation.[1]A 6-year-old female child was admitted to our hospital with complaints of fever, cough, and breathlessness on exertion, on and off for the past 1 year. General physical examination was unremarkable. On cardiovascular system examination, grade 3/6 systolic murmur was heard along the left sternal border. Electrocardiogram showed a heart rate of 95 beats/min, in sinus rhythm. Chest X-ray showed cardiothoracic ratio of 0.6. Transthoracic echocardiogram [Figure 1] showed aorto-left ventricular tunnel from left coronary–noncoronary commissure to the left ventricle at the base of noncoronary cusp. She was taken up for surgery. After establishing cardiopulmonary bypass with aorta and bicaval cannulation, aorta was cross-clamped. Aorta was transected and cold blood cardioplegia was given through the coronary ostia. Aortic end of the tunnel [Figure 2] was found as an opening extending behind the left coronary cusp–noncoronary cusp commissure into both sinuses. A silk thread [Figure 3] is passed from the opening in the noncoronary sinus, which came out through the opening in the left ventricle. Similarly, another silk thread is passed from the opening in the left coronary sinus, which also came out through the same opening in the left ventricle. On further examination, we found out that both the openings were found out to be single opening extending behind the commissure. The left ventricle end of the tunnel was closed with 0.4-mm polytetrafluoroethylene (PTFE) patch using 6-o polypropylene pledgeted interrupted sutures. Aortic end of the orifice was also closed with a small PTFE patch using 6-o polypropylene pledgeted interrupted sutures. Aortic valve was inspected and commissure was resuspended on to the patch. The patient was weaned off from cardiopulmonary bypass gradually. Postoperative transesophageal echocardiogram revealed no communication between aorta and left ventricle. The patient is doing well without any symptoms at 1-year follow-up.
Figure 1
Transthoracic echocardiogram in theparasternal long-axis view showing aorto-left ventricular tunnel from left coronary–noncoronary commissure to left ventricle at the base of noncoronary cusp
Figure 2
Intraoperative picture showing aortic end of the tunnel which was found as an opening extending behind the left coronary cusp–noncoronary cusp commissure into both sinuses
Figure 3
Line diagram showing silk passing through the aortic end of the tunnel, which was found as an opening extending behind the left coronory cusp–noncoronory cusp commissures into both sinuses
Transthoracic echocardiogram in theparasternal long-axis view showing aorto-left ventricular tunnel from left coronary–noncoronary commissure to left ventricle at the base of noncoronary cuspIntraoperative picture showing aortic end of the tunnel which was found as an opening extending behind the left coronary cusp–noncoronary cusp commissure into both sinusesLine diagram showing silk passing through the aortic end of the tunnel, which was found as an opening extending behind the left coronory cusp–noncoronory cusp commissures into both sinusesHovaguimian et al.[2] defined four types of aorto-left ventricular tunnel. Most common site of origin of the aortic orifice of the tunnel is from the right coronary sinus, on the anterolateral side of the ascending aorta.[1] There are some rare instances of it originating from left coronary sinus.[34] In our patient, the aortic orifice of the tunnel originated from the left coronary–noncoronary commissure extending into both sinuses and the tunnel was posterolateral to the ascending aorta.Clinical presentation depends upon the type of aorto-left ventricular tunnel with the development of congestive cardiac failure, common to all the types.[34]Regardless of the presentation, even if the patient is asymptomatic, surgical treatment is advocated to prevent the development of complications such as aortic regurgitation and congestive cardiac failure. Best time for surgery is infancy because left ventricular function and size can become normal easily. Serino et al.[5] reported that closing the aortic defect by direct suture may result in progressive distortion of the cusps, which could result in regurgitation and the need for valve replacement. Hence, patch technique may be beneficial, which can act as a support to dilated aortic sinus. However, patch should be trimmed appropriately to avoid any distortion to aortic valve. Hence, we preferred to close both the sides of the tunnel using small 0.4 mm, appropriately trimmed PTFE patch.To conclude, aorto-left ventricular tunnel is a rare extracardiac communication between aorta and left ventricle and if diagnosed should be operated immediately for the reasons stated above.[6]
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