1. Aortico-Left Ventricular Tunnel
Seoul National University Hospital
Department of Thoracic & Cardiovascular Surgery

2. Aortico-Left Ventricular Tunnel
Definition
A short abnormal pathway, beginning in an
aneurysmal dilation of the right sinus of Valsalva
(rarely, the left), just to the left of orifice of right
coronary artery, and passing through upper end
of the ventricular septum to open into the left
ventricular cavity.
This is a rare congenital cardiac anomaly first
described by Levy and Lillehei in 1963.

3. Suggested Etiology 1. An example of coronary artery fistula
2. Persistence of embryonic rests of 5th arch
3. Intrauterine rupture of sinus Valsalva
4. Early aortic dissection as in Marfan

4. Morphology of Aortico-Left Ventricular Tunnel
Mostly, the aortic orifice is anterior and just downstream from
commissural level of AV and separated from right sinus of
Valsalva by a prominent transverse supravalvar ridge.
The tunnel passes directly downward, beside AV and through
the junction between aorta and ventricular septum.
The tunnel displace the outlet portion of septum into the RV
and produce subpulmonary stenosis.
A VSD may coexist, and rarely the tunnel may communicate
with the infundibulum of RV rather then LV.

5. Classification (Hovaguimian)
Type 1 : slit like opening with no valve distortion
(24%)
Type 2 : large extracardiac aneurysm (44%)
Type 3 : intracardiac aneurysm with or without
RVOTO (24%)
Type 4 : combination of 2 & 3

6. Aortico - Left Ventricle Tunnel

7. Clinical Features & Natural History
Incidence ; 0.1% of all CHD
Usually 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.

8. Operation of Aortico-Left Ventricular Tunnel
Indication
The diagnosis is an indication for operation and the operation
should be performed as early as possible.
Technique
If possible, both ends of the tunnel are closed, aortic end is
closed by placing a pericardial patch, and ventricular end is
closed by suture or patch.
Particular care is taken to avoid left ventricular distention.
Results
Hospital death : 5-20%
Most patients have at least mild AR.
The reason for postoperative AR is poorly understood.