Abnormal Communication between the Aorta and Left Ventricle

Abstract

LEVY et al.1 described "aortico-left ventricular tunnel" as an abnormal communication that begins in the ascending aorta above the level of the coronary arteries, bypasses the aortic valve, and terminates in the left ventricle, resulting in aortic insufficiency. The authors described three cases and stated that four similar cases had been previously described. A review of the original papers2-5 suggests, however, that in three instances the history and anatomic findings were more compatible with rupture of a congenital aneurysm of a sinus of Valsalva than with an aortico-left ventricular tunnel. Levy et al.' made the point that in their three cases, and in another previously described by Edwards,3 the tunnel originated or joined the ascending aorta above the sinus of Valsalva and the sinuses were normal. Furthermore, evidence of the presence of the tunnel appeared during infancy, suggesting that it was present at birth and not the result of a postnatal rupture.An abnormal communication between the aorta and the left ventricle may also be secondary to a rupture of either a congenital or acquired aneurysm of a sinus of Valsalva. Congenital aneurysms usually come to the attention of the physician only after rupture into one of the adjacent cardiac chambers, although the diagnosis prior to rupture can be made by angiocardiography.6 Up to 1961 Sakakibara and Konno7 found 52 well-documented cases of aneurysm of the sinuses of Valsalva with rupture, and in three of these, 564 an aneurysm of the right sinus had ruptured into the left ventricle. The average age of rupture, as ascertained by history and physical examination, of the entire 52 cases was 32 years, and the youngest with rupture into Case Report This white male infant was first seen at the age Circulation, Volume XXXI, April 1965 From the

Clinical implications of prenatal diagnosis of aorto-left ventricular tunnel on postnatal treatment and final outcome

“…Until recently, prenatal AVLT diagnosis was mostly based on indirect signs such as LV enlargement and hypertrophy and ascending aorta dilatation and regurgitation and was made only after multiple fetal scans 2,4 . Direct tunnel visualization was presented only few of the reported cases 8,9 . Recently, a "cockade sign" -a double ring around the aortic annulus was introduced as a diagnostic clue for a correct fetal AVLT diagnosis 5 .…”

“…Another hypothetical explanation for the bad outcome might be a possible pre-existing aortic wall delamination which, when the probe was placed into the aortic tunnel end, resulted in ascending aorta fusion with the tunnel. Aortic wall delamination as a possible etiology of ALVT was first speculated by Cooley 9 who found mucopolysaccharide deposits in aortic tunnel wall and adjacent ascending aorta 9 . Such tunnel histology was not confirmed by others.…”

Aorto-left ventricular communication after closure. Late postoperative problems.

“…[3][4][5][6] Unfortunately, later aortic valve repair has failed in our hands so that ultimately aortic valve replacement has been necessary in some cases.…”

Congenital Aneurysm of the Pulmonary Sinus of Valsalva

“…The great preponderance of congenital aortic sinus aneurysms have manifested themselves beyond the second decade, and at one time it was thought that rupture never occurred in young children.2' Subsequently a small number of wvell-documented22 23 and other less compelling24-27 cases occurring in childhood have been recorded. In this age group, sinus aneurysms must be distinguished from aortico-left ventricular tunnels.28 The latter are characterized by having their point of origin above the ostia of the coronary arteries and having continuation of the aortic media into the tunnel.28 29 The present lesion displays only sparse elastic tissue in its wall and its saccular configuration is much more in keeping with the congenital sinus aneurysms of the aorta. None of the reports of comparable aortic sinus cases in the pediatric age group have included information on the relationship of the media to the site of dissection.…”