Echocardiographic-anatomical correlations in aorto-left ventricular tunnel

Aorta to left ventricle tunnel presenting with cardiac failure in a neonate

We report an unusual case of an aorta to left ventricular communication in a neonate presenting with cardiac failure. Although extremely rare, this defect is the most common cause of abnormal blood flow from the aorta to a ventricle in infancy. Early diagnosis and prompt surgical repair are critical to management and results are generally excellent. Long-term follow-up is required to monitor for aortic insufficiency.

Aorto-Left Ventricular Tunnel - Prenatal Diagnosis and Outcome

PURPOSE

 Aorto-left ventricular tunnel (ALVT) is an extremely rare, albeit prenatally detectable, extracardiac channel that connects the ascending aorta to the cavity of the left ventricle.

MATERIALS AND METHODS

 All ALVTs diagnosed prenatally (2006-2020) in five tertiary referral centers were retrospectively assessed for prenatal ultrasound findings, intrauterine course, postnatal outcome, and surgical treatment. We focused on the size of the tunnel and alterations of perfusion of the left ventricular outflow tract and aortic arch.

RESULTS

 11 fetuses were diagnosed with ALVT at a mean gestational age of 24.8 weeks. All cases were associated with severe dilatation of the left ventricle and a to-and-fro flow in the left outflow tract. Signs of congestive heart failure were present in five fetuses, four of which were terminated and one of which died in the neonatal period. One fetus died in utero at 34 weeks without prior signs of cardiac failure. Of the five survivors, two underwent the Ross procedure. In both cases the prenatal left ventricular outflow was exclusively via a large tunnel. The remaining three neonates underwent patch closure of the tunnel. In these cases, the prenatal outflow of the left ventricle was via the aortic valve and simultaneously over the tunnel.

CONCLUSION

 Prenatal diagnosis of ALVT should be considered in the presence of left ventricular hypertrophy, dilatation of the aortic root, and to-and-fro flow in the aortic outflow tract. Signs of heart failure are associated with an unfavorable outcome. Large tunnels, particularly in combination with the absence of flow over the aortic valve, may be an unfavorable predictor of surgical repair.

Aorto-ventricular tunnel with three orifices: a unique case report diagnosed by transthoracic echocardiography

BACKGROUND

Aorto-ventricular tunnel (AVT) is an abnormal communication channel between the ascending aorta and the ventricle. It commonly has two orifices, i.e., one aortic opening and one ventricular opening. In this study, we present a unique case of AVT with three orifices: one aortic opening, one LV opening, and one RV opening.

CASE PRESENTATION

A 64-year-old male presented with chest discomfort and dyspnea on exertion lasting the past six months. Physical examination revealed a grade 4/6 continuous biphasic murmur along the left sternal edge and a grade 3/6 systolic murmur at the apex. Transthoracic echocardiography (TTE) demonstrated: (1) an AVT with three orifices, i.e., one aortic opening, one LV opening, and one RV opening. The LV and RV openings were located in the left and right ventricular outflow tracts, respectively. (2) The aortic valve (AV) was calcified with a small aneurysm at the non-coronary cusp. (3)The mitral valve (MV) chordal rupture of the P2 and P3 segments was observed in the posterior leaflet with severe eccentric regurgitation. Subsequent coronary computed tomography angiography (CTA) further confirmed the diagnosis of AVT with three openings, and clarified the coronary arteries normally arose from the aortic sinuses. The patient was then referred for surgical treatment, consisting of closure of three AVT orifices, AV replacement, and MV replacement. Six months following surgery, the patient was asymptomatic. TTE demonstrated normal mechanic AV and MV function, and there was no residual shunt among the ascending aorta, LV and RV.

CONCLUSIONS

It is the first case to report an AVT with three orifices. This paper described the entire process from diagnosis to treatment of this unique case, thus providing some novel insights into AVT.

The aorto-left ventricular tunnel from a fetal perspective: original case series and literature review

Introduction

Aorto‐left ventricular tunnel (ALVT) accounts for <0.1% of congenital heart defects. Evidence on the prognosis from a fetal perspective is limited. With this retrospective international case series, we provide information on the outcome of fetuses with ALVT.

Methods

All members of the Association for European Pediatric and Congenital Cardiology's (AEPC) fetal working group and fetal medicine units worldwide were invited for participation. We observed antenatal parameters, neonatal outcome and postnatal follow‐up. Additionally, a systematic search of the literature was performed.

Results

Twenty fetuses with ALVT were identified in 10 participating centers (2001–2019). Fetal echocardiographic characteristics of ALVT included an increased cardiac–thorax ratio (95%), left ventricular end‐diastolic diameter (90%) and a dysplastic aortic valve (90%). Extracardiac malformations were rare (5%). Eight fetuses died at a median gestational age (GA) of 21 + 6 weeks (range, 19–24): all showed signs of hydrops prior to 24 weeks or at autopsy. All others (60%, 12/2) were live–born (median GA 38 + 4, range 37–40), underwent surgery and were alive at last follow up (median 3.2 years, range 0.1–17). The literature reported 22 ALVT fetuses with similar outcome.

Conclusions

In the absence of fetal hydrops, ALVT carries a good prognosis. Fetuses who survive to 24 weeks without hydrops are likely to have a good outcome.

What's already known about this topic?

Aorto‐left ventricular tunnel (ALVT) is an extremely rare diagnosis that may cause congenital heart failure and fetal hydrops, leading to fetal or neonatal death.

A few case reports show that after corrective surgery in the neonatal period, cases with ALVT tend to have a good prognosis.

What does this study add?

This is the first study that evaluates prenatal characteristics, prognostic parameters and outcome following a prenatal diagnosis of ALVT in a cohort of cases worldwide, including a systematic review of the literature as well.

In the absence of fetal hydrops, ALVT carries a good prognosis. Fetuses who survive to 24 weeks without hydrops are likely to have a good outcome.

A Review of the Surgical Management of Aorto-ventricular Tunnels

We present a synthesis of 95 published investigations of the exceedingly rare tunnels that can exist between the aortic root and the left or right ventricles. From the 220 suitable cases included in these investigations, we reviewed the clinical presentations, modalities used for diagnosis, surgical approaches, and outcomes. Diagnostic information was provided by clinical presentation, radiographic findings, saline contrast echocardiography, computed tomographic angiocardiography, magnetic resonance imaging, cardiac catheterization, and angiocardiography. These techniques elucidated the coronary arterial origins and associated defects and defined the disease before surgery. Patients occasionally present with an asymptomatic cardiac murmur and cardiomegaly, but most suffer cardiac failure in the first year of life when the tunnel enters the left ventricle. Antenatal diagnosis by fetal echocardiography is reliable after 18 weeks of gestation. Associated defects, involving the proximal coronary arteries or the aortic or pulmonary valves, are present in nearly half the cases. Prompt diagnosis and surgical repair are important for a favorable outcome. Overall, operative mortality has been cited to be between 3% and 8.3%. Associated congenital coronary arterial anomalies, residual severe aortic stenosis, poor left ventricular function, and rupture of an infected suture line have been the reported causes of death. Despite early surgical intervention, an incidence of 16% to 60% postoperative residual aortic regurgitation of varying severity has been reported. The requirement of further repair or replacement of the aortic valve ranges from 0% to 50%. We submit that an increased appreciation of these details relative to the tunnels will contribute to improved surgical management.

Prenatal Diagnosis of Aorto-Left Ventricular Tunnel With Dysplastic Bicuspid Aortic Valve: From Fetal Cardiac Failure to Favorable Outcome

Aorto-left ventricular tunnel (ALVT) is a rare congenital heart defect. Surgery has to be performed early to avoid life-threatening complications. Prenatal diagnosis of this defect is challenging. We report a case of ALVT diagnosed in a fetus showing premature severe cardiac failure at 24 GA. The new born was operated at day 3 of life with good results. Two years later, he is still doing well recovering a complete normal cardiac function. ALVT should be suggested in front of any fetal cardiac failure. Thanks to early diagnosis, prompt neonatal management can be organized and allows positive outcome.

Aorto-left ventricular tunnel with anomalous origin of right coronary artery and bicuspid aortic valve: a case report

Background

Aorto-left ventricular tunnel (ALVT) is a rare congenital extracardiac channel that connects the ascending aorta to the left ventricle. To our knowledge, no case has been thus far reported as ALVT with both anomalous origin of right coronary artery (AORCA) and bicuspid aortic valve (BAV).

Case presentation

We reported a case of a 5-year-old female diagnosed as ALVT with accompanying AORCA and BAV which had been previously misdiagnosed as aortic regurgitation (AR) triggered by BAV. Additionally, a special modality of ALVT was confirmed in this case during the surgery in which the tunnel was formed by the separation between the roots of two aortic leaflets during the diastolic period.

Conclusions

ALVT with both AORCA and BAV is clinically uncommon and the aberrant tunnel in ALVT can be formed by the gap between the roots of two aortic leaflets. Besides, ALVT with BAV might easily lead to an inaccurate diagnose as aortic regurgitation caused by BAV. Cardiac surgeons should be alerted for differential diagnosis of ALVT with BAV and isolated bicuspid aortic valve (BAV) causing aortic regurgitation (AR).

Aorto-Right Ventricular Tunnel in Transposition of the Great Arteries

Aorto-ventricular tunnel is an extremely rare congenital heart defect, consisting of failure of attachment of an aortic leaflet along the semilunar hinge. In all published reports the leaflet involved was either the right coronary leaflet, most frequently, or the left coronary leaflet, in most of the cases opening toward the left ventricle, with only one-eighth of the reported cases communicating with the right ventricle. Treatment of the aorto-ventricular tunnel has been anecdotally reported by interventional closure with a device and more frequently with surgical approach, either as an isolated malformation or as associated lesions. To the best of our knowledge, the presence of an aorto-ventricular tunnel of the non-adjacent aortic leaflet in transposition of the great arteries has never been reported. We have observed an aorto-ventricular tunnel involving the non-adjacent leaflet of the aortic root, which after arterial switch became the pulmonary root. The patient presented 18 years after the arterial switch with progressive dilatation of the right ventricle due to severe degree of pulmonary valve regurgitation, confirmed by echocardiography and cardiac MRI. Indication for surgery was given with the plan for a pulmonary valve implantation. Because of the intra-operative finding of disconnection of the anterior leaflet of the pulmonary valve (former aortic valve) along the semilunar hinge, the surgical plan was modified and the anterior leaflet was attached to the valve annulus, with subsequent plasty in correspondence with the right and left commissurae to reduce the size of the dilated annulus to normal diameter. The post-operative course was uneventful, with extubation after few hours and discharge 4 days after surgery, with echocardiography showing trivial degree of pulmonary valve regurgitation. The patient remains in good conditions 6 months after surgery.

Valvar aortico-ventricular tunnel: an insight into the development of the great arteries

Aorto-left ventricular tunnel is a rare congenital heart lesion, with an incidence of <0.1% of all CHD. We present a unique case of a valvar aorto-left ventricular tunnel in a neonate, in belief that our findings may shed some light on the developmental origins of this lesion.

Clinical value of diagnosing aortico-left ventricular tunnel by echocardiography

In order to assess the clinical value of echocardiography in the diagnosis of aortico-left ventricular tunnel (ALVT) the echocardiographic data and clinical manifestations of six patients with ALVT were analyzed in the present study. Based on the results, a comprehensive study was conducted regarding 147 cases from related documents. Six patients were confirmed with ALVT by surgery. The echocardiographic images of the patients revealed an abnormal communication beginning in the ascending aorta above the coronary arteries, bypassing the aortic valve, and ending in the left ventricle. The color Doppler flow imaging showed a high-speed to- and -fro flow with or without the involvement of the aortic valve. According to Hovaguimian type casting, there were two cases of type I, two cases of type III, one case of type IV, and one case of type II (postoperative recanalization). Of the 153 cases reported, the accuracy rate of the ultrasound diagnosis was 79.6%, the misdiagnosis rate was 17.1%, and the missed diagnostic rate was 3.3%. In conclusion, echocardiography is the preferred method for non-invasive preoperative diagnosis of the ALVT and can accurately describe the type and involvement of the cardiac structure.

First successful repair of an aortico-to-right ventricular tunnel (ARVT) in d-transposition of the great arteries with aortic valve atresia and ventricular septal defect

The presented case reports on the first successful complex biventricular repair in a neonate with an aortico-to-right ventricular tunnel and dextrotransposition of the great arteries complicated by aortic atresia.

Prenatal diagnosis and successful outcome in neonate of aorto-left ventricle tunnel

Aorto-left ventricular tunnel (ALVT) is an abnormal congenital communication between the ascending aorta and the left ventricle. Prenatal diagnosis is rare and can be misinterpreted as aortic insufficiency on fetal echocardiogram. We present a case of ALVT diagnosed in a fetus who underwent successful early neonatal surgical repair.

Aortico-left ventricular tunnel: the elusive diagnosis

We present a case of an infant prenatally diagnosed with bilateral outflow-tract obstruction and severe aortic regurgitation who underwent cardiac transplantation at 45 days of life. Aortico-left ventricular tunnel was subsequently diagnosed on pathologic examination of the explant heart. Aortico-left ventricular tunnel is a rare congenital cardiac malformation and can remain undiagnosed if the clinician has a low level of suspicion. Aortico-left ventricular tunnel should be considered in any fetus or newborn with aortic regurgitation.

Prenatal and pathologic features of aorto-left ventricular tunnel causing fetal hydrops and intrauterine demise

ABSTRACT Aorto-left ventricular tunnel (ALVT) is a rare congenital heart anomaly of unclear pathogenesis causing left ventricular volume overload. Most descriptions are from surgical corrections in the neonatal and infantile period, and little is known about ALVT in utero. Here we describe a case of ALVT ending in intrauterine demise with fetal hydrops at 30 weeks gestational age. Prior echocardiography showed features suggesting the presence of an ALVT, and an ALVT circumventing the left coronary leaflet of the aortic valve was confirmed at autopsy. Marked cardiomegaly and dilatation were present along with diffuse myocardial infarction. Other potential causes of fetal hydrops were not found, and genetic analysis, including analysis for RAS pathway mutations, did not reveal any detectable abnormalities. The presentation as intrauterine demise suggests that the architecture of this ALVT compromises cardiac function to a greater degree than the more typical defects discovered in the neonatal period.

Congenital aortico-left ventricular tunnel in fetuses and infants

Congenital aortico-left ventricular tunnel (ALVT) is a rare congenital heart disease. A 27-year-old woman was referred to us at 37 weeks gestation with fetal cardiac enlargement. The left ventricle (LV) of the fetus was enlarged. Fetal aortic valve (AoV) ring diameter spread was observed. Back flow from the AoV margins to the LV was observed. The prenatal diagnosis of the fetus was aortic regurgitation (AR). A male neonate was delivered by cesarean section at 40 weeks gestation. We made the diagnosis of ALVT because the aorta and the LV of the neonate showed a tunnel with blood flow on echocardiography. We took another look at the fetal echocardiography. The neonate underwent surgery for exacerbation of heart failure on the 7th day after birth. Trivial flow from the tunnel and mild AR were observed after surgery.

Unusual aortic valve anomaly in the fetus: a case report

Aortic valve anomalies in fetal life usually concern aortic valve stenosis, in severe forms associated to left ventricular impairment - endocardial fibroelastosis and mitral valve insufficiency. Isolated aortic regurgitation in utero is infrequent and is usually considered to be due to a rare anomaly: aorto-left ventricular tunnel. We describe an unusual case of fetal aortic valve anomaly with severe dysplasia, with a marked regurgitant flow through the aortic valve, passing in a retrograde way from the duct, associated with a marked left ventricular endocardial fibroelastosis and dysfunction, resulting in the fatal outcome of the case.

Surgical repair of aorto-ventricular tunnel

This report presents a trans-aortic trans-infundibular double-patch repair of an aorto-left ventricular tunnel in a 17-day old male child. It reviews the literature on aorto-ventricular tunnels and debates strategic and surgical options available to correct these defects. Diagnosis of the tunnel in the case described herein was made prenatally. The child was presented with left ventricular dilatation with early and progressive signs of congestive heart failure. Decision for early surgical correction was made considering the quantum of regurgitant jet, diastolic backflow in the aorta and consequent left ventricular dilatation. After establishing cardiopulmonary bypass and arresting the heart, the aorta was transversely opened above the sinotubular junction and the tunnel identified. Aortic valve morphology and the coronary ostia not involved in the tunnel were carefully investigated. Through a transverse infundibulotomy, the thinned outer wall of the tunnel abutting the posterior wall of the infundibular septum was slit open vertically, thus clearly defining the aortic and the left ventricular orifices. The distal tunnel orifice, now presenting as a subaortic Ventricular septal defect (VSD), was closed using a xenopericardial patch and running polypropylene 7-0 stitches. The aortic end of the tunnel was closed in a similar fashion through the aortotomy, remaining clear of the right coronary artery and respecting the aortic valve geometry. The marsupialized wall of the tunnel as seen through the infundibulotomy was sutured with polypropylene stitches. The aortotomy and right ventriculotomy were closed. The postoperative course was uneventful. A follow-up echocardiography at 2 years showed a perfect outcome with no residual tunnel, no aortic stenosis and trivial aortic regurgitation.

Aorto-ventricular tunnel

Aorto-ventricular tunnel is a congenital, extracardiac channel which connects the ascending aorta above the sinutubular junction to the cavity of the left, or (less commonly) right ventricle. The exact incidence is unknown, estimates ranging from 0.5% of fetal cardiac malformations to less than 0.1% of congenitally malformed hearts in clinico-pathological series. Approximately 130 cases have been reported in the literature, about twice as many cases in males as in females. Associated defects, usually involving the proximal coronary arteries, or the aortic or pulmonary valves, are present in nearly half the cases. Occasional patients present with an asymptomatic heart murmur and cardiac enlargement, but most suffer heart failure in the first year of life. The etiology of aorto-ventricular tunnel is uncertain. It appears to result from a combination of maldevelopment of the cushions which give rise to the pulmonary and aortic roots, and abnormal separation of these structures. Echocardiography is the diagnostic investigation of choice. Antenatal diagnosis by fetal echocardiography is reliable after 18 weeks gestation. Aorto-ventricular tunnel must be distinguished from other lesions which cause rapid run-off of blood from the aorta and produce cardiac failure. Optimal management of symptomatic aorto-ventricular tunnel consists of diagnosis by echocardiography, complimented with cardiac catheterization as needed to elucidate coronary arterial origins or associated defects, and prompt surgical repair. Observation of the exceedingly rare, asymptomatic patient with a small tunnel may be justified by occasional spontaneous closure. All patients require life-long follow-up for recurrence of the tunnel, aortic valve incompetence, left ventricular function, and aneurysmal enlargement of the ascending aorta.

Surgical correction of aortico-left ventricular tunnel

Aortico-left ventricular tunnel is a rare, paravalvular communication of unclear etiology between the ascending aorta and the left ventricle. The resultant regurgitant diastolic blood flow leads to varying degrees of volume overload and congestive heart failure. Diagnosis is typically made postnatally with echocardiography. Surgical correction is the treatment of choice consisting of either patch closure or primary repair of the aortic orifice. Prognosis is good, although a significant percentage of patients will eventually require valve replacement because of progressive aortic valvular insufficiency.

An unusual case of aorto-left ventricular tunnel

An asymptomatic 4-year-old child was referred to our Institution with a provisional diagnosis of severe aortic valvar regurgitation in association with a ventricular septal defect. Intraoperatively, the aortic valve appeared bicuspid, and a tunnel of 7 mm diameter extending between the aorta and the left ventricle was found dividing the anterior commissure into two hemi-commissures. Repair was achieved by reconstructing the anterior commissure by direct reapproximation, and simultaneous obliteration of the aortic side of the tunnel. The aortic valvar leaflet was resuspended onto the arterial wall. This combined approach will hopefully reinforce the poorly supported aortic sinus, and may maintain aortic valvar competence over the long term. Our intraoperative diagnosis of aorto-left ventricular tunnel suggests consideration of this diagnosis when evaluating any patient with suspected aortic valvar incompetence.

The spectrum of fetal cardiac malformations

Increasingly, paediatric cardiologists are called upon to diagnose cardiac malformations prenatally. In the main, the types of malformation seen during fetal life will be similar to those documented postnatally, but the frequency with which they are encountered, as well as the views that can be used for diagnosis, will be different. This review aims to describe the anatomic spectrum of malformations seen in 917 fetal hearts examined consecutively following prenatal diagnosis. The distribution of anomalies is illustrated in terms of a simple sweep through the fetal thorax passing from the four-chamber plane to the outflow tracts, and then to more cranial views of the mediastinum. Two-thirds of the anomalies described would have been detectable in the four-chamber plane. Some, such as tricuspid valvar abnormalities, will alter the normal appearances of the four-chambers dramatically. In terms of the overall spectrum, however, such obvious abnormalities only form a minor part of the total number. Others, such as atrioventricular septal defect, will often require closer inspection of intracardiac anatomy, but will make up a large proportion of the entire cohort. Up to one third of the anomalies in the series would have required views more cranial to the four-chamber plane of section. In these, it would have been necessary to examine the nature of the left ventricular outflow tract, the crossing of the two outflows, or else the arterial arches in order to secure detection. In the fetus, these and other planes must be considered by the echocardiographer in order completely to detect and document the entire spectrum of cardiac abnormalities likely to be encountered.

Prenatal diagnosis of an aortico-left ventricular tunnel

Aortico-left ventricular tunnel is a rare abnormal communication between the ascending aorta and the left ventricle. Early diagnosis and prompt surgical repair prevent congestive heart failure or consecutive valvular insufficiency. However, in utero diagnosis of this heart malformation has been rarely described and none of those children survived. We report on a case of aortico-left ventricular tunnel detected at 32 weeks' gestation with a favourable outcome after surgical repair at three months of age.

Aorto-Left Ventricular Communication through Extracardiac Tunnel

An asymptomatic 24-year-old man underwent surgical correction of an aorto-left ventricular tunnel. A 1-cm opening was found 1 cm above the commissure of the left and right coronary cusps, which communicated with the left ventricle. It was successfully closed by direct suture.

Surgical anatomy of aorto-left ventricular tunnel

BACKGROUND

Owing to the rarity of aorto-left ventricular tunnel, surgical experience with this condition is generally limited. The anatomic configuration remains to be clarified in the light of better understanding of the normal aortic root.

METHODS

Two autopsied hearts with aorto-left ventricular tunnel were examined and compared with four normal heart specimens. The normal hearts were sectioned in a variety of planes to display the ventriculoarterial junction.

RESULTS

The leaflets of the pulmonary valve in both normal and abnormal hearts have semilunar attachments to a sleeve of freestanding ventricular musculature, the infundibulum. An extensive fibrofatty tissue plane then interposes between the freestanding infundibulum and the aortic sinuses. The aorto-left ventricular tunnels in the abnormal hearts pass within this tissue plane. The aortic orifice of the tunnel is distal to the level of the sinutubular junction, whereas the ventricular orifice is located within the interleaflet triangle between the right and left aortic sinuses.

CONCLUSIONS

Aorto-left ventricular tunnels bypass the normal ventriculoarterial junction but do not penetrate the septal musculature. This has implications for the fine-tuning of surgical repair.

Aortico-left ventricular tunnel in fetuses and infants

BACKGROUND

Aortico-left ventricular tunnel is a rare congenital abnormal communication between the aorta and the left ventricle presenting in early childhood as aortic regurgitation and cardiac failure. This condition has rarely been reported in fetuses. Operation is the only treatment, and postoperative aortic incompetence could be related to the age or the type of repair.

METHODS

We conducted a retrospective, two-institution review, from 1983 to 1995, of aortico-left ventricular tunnel diagnosed in utero and before 6 months of age.

RESULTS

Three cases of aortico-left ventricular tunnel were diagnosed in utero by Doppler echocardiography between 22 and 24 weeks' gestation. Prenatal aortico-left ventricular tunnel was associated with severe left ventricular dysfunction, aortic valve anomalies, and fetal hydrops. One death occurred in utero and one immediately after birth, and in 1 case pregnancy was interrupted. In these 3 cases the diagnosis was confirmed by autopsy. Three neonates and 2 infants had the diagnosis of aortico-left ventricular tunnel made after birth and underwent successful surgical repair. At short and midterm follow-up all patients are alive and aortic valve regurgitation is absent or trivial.

CONCLUSIONS

This series shows that aortico-left ventricular tunnel covers an anatomic spectrum of lesions. Cases diagnosed in utero by Doppler echocardiography are characterized by severe ventricular dysfunction, associated aortic valve lesions, and poor outcome. Postnatal cases represent the more favorable end of the spectrum, with no associated lesions, and can be repaired without mortality and with good functional results.