Presentation on theme: "Aortico-Left Ventricular Tunnel"— Presentation transcript:
1Aortico-Left Ventricular Tunnel Seoul National University HospitalDepartment of Thoracic & Cardiovascular Surgery
2Aortico-Left Ventricular Tunnel DefinitionA short abnormal pathway, beginning in ananeurysmal dilation of the right sinus of Valsalva(rarely, the left), just to the left of orifice of rightcoronary artery, and passing through upper endof the ventricular septum to open into the leftventricular cavity.This is a rare congenital cardiac anomaly firstdescribed by Levy and Lillehei in 1963.
3Suggested Etiology 1. An example of coronary artery fistula 2. Persistence of embryonic rests of 5th arch3. Intrauterine rupture of sinus Valsalva4. Early aortic dissection as in Marfan
4Morphology of Aortico-Left Ventricular Tunnel Mostly, the aortic orifice is anterior and just downstream fromcommissural level of AV and separated from right sinus ofValsalva by a prominent transverse supravalvar ridge.The tunnel passes directly downward, beside AV and throughthe junction between aorta and ventricular septum.The tunnel displace the outlet portion of septum into the RVand produce subpulmonary stenosis.A VSD may coexist, and rarely the tunnel may communicatewith the infundibulum of RV rather then LV.
5Classification (Hovaguimian) Type 1 : slit like opening with no valve distortion(24%)Type 2 : large extracardiac aneurysm (44%)Type 3 : intracardiac aneurysm with or withoutRVOTO (24%)Type 4 : combination of 2 & 3
7Clinical Features & Natural History Incidence ; 0.1% of all CHDUsually have severe AR, & symptoms & signs of severe AR.3. The age and severity of symptoms are related to the size of the tunnel and the magnitude of the AR.4. Some patients present as neonate and others with a smaller tunnel may present beyond 2nd decade of life.5. When symptoms are present, the natural history thereafter is that of severe AR.
8Operation of Aortico-Left Ventricular Tunnel IndicationThe diagnosis is an indication for operation and the operationshould be performed as early as possible.TechniqueIf possible, both ends of the tunnel are closed, aortic end isclosed by placing a pericardial patch, and ventricular end isclosed by suture or patch.Particular care is taken to avoid left ventricular distention.ResultsHospital death : 5-20%Most patients have at least mild AR.The reason for postoperative AR is poorly understood.