Surgery for an Aorto-Left-Ventricular Tunnel in Close Proximity to the Right Coronary Artery: A Case Report

Aorto-left ventricular tunnel (ALVT) is a rare congenital extracardiac communication between the ascending aorta and the left ventricle (LV) that originates above the aortic valve leaflets; approximately 177 cases have been published. We report an 11-month-old boy referred after a “to-and-fro” murmur was detected on routine examination. External transthoracic echocardiography (TTE) had suggested a subpulmonary ventricular septal defect (VSD) with an aneurysm of the right ventricular outflow tract (RVOT). At our institution, TTE showed a dilated LV (z-score +4.2) with preserved ejection fraction (EF, approximately 60%) and a tunnel with predominantly diastolic flow from the ascending aorta into the LV. Computed tomography angiography (CTA) with 3D reconstruction confirmed a Hovaguimian type II ALVT whose aortic orifice lies approximately 8 mm craniodorsal of the right coronary artery (RCA) ostium, without communication with the RCA or the RVOT. Interdisciplinary Heart Team recommended surgical closure of the tunnel. The ventricular orifice was closed with a patch and the aortic orifice by direct suture; the RCA ostium and the aortic valve were confirmed intraoperatively not to be compromised. Transient postoperative LV systolic dysfunction (EF 28%) resolved by postoperative day five. At fifteen-month follow-up, LV size and function were normal, aortic regurgitation was minimal, and there was no residual tunnel flow. Multimodality imaging that defined the coronary relationship enabled a repair preserving both the RCA and the aortic valve.