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Aortic-Right Ventricular Tunnel - Florentino Vargas et al.

Ann Thorac Surg
Aortico–Right Ventricular Tunnel
Florentino J. Vargas, MD, Alberto Molina, MD,
Juan C. Martinez, MD, Maria E. Ranzini, MD, and
Juan C. Vazquez, MD
Unit of Pediatric Cardiovascular Surgery, Hospital Italiano,
Buenos Aires, Argentina
A successful operation on an infant with a tunnel
through which the aorta communicated with the right
ventricle is reported. The diagnosis was suspected preoperatively on the basis of two-dimensional Doppler
color echocardiography and confirmed by cardiac catheterization. The aortico–right ventricular tunnel originated independently from the left coronary ostium and
above the sinus of Valsalva. Patch closure from inside the
tunnel under deep hypothermia was successfully performed. Follow-up is satisfactory 5 years later.
(Ann Thorac Surg 1998;66:1793–5)
© 1998 by The Society of Thoracic Surgeons
lthough the anatomic and surgical aspects of
aortico–left ventricular tunnel have been well
documented during recent years, information regarding
aortico–right ventricular tunnel is scarce. The data reported are still insufficient to consider this as an isolated
entity. We report the anatomic findings from a patient
who was operated on successfully in whom the diagnosis
of aortico–right ventricular tunnel was made preoperatively.
A 7-month-old boy weighing 4,000 g was admitted with
congestive failure. The diagnosis of coronary artery fistula had been made in another institution. A harsh
continuous murmur was heard over the left precordium.
A chest radiograph showed cardiomegaly and increased
pulmonary flow. An electrocardiogram showed biventricular hypertrophy and a pattern of anteroseptal ventricular wall infarction. The echocardiogram (Fig 1) displayed a huge tunnel connecting the aorta with the right
ventricle. This was aneurysmatic at the aortic origin and
appeared to be included within the myocardium of the
anterior ventricular septum. This intramural tunnel
opened close to the trabecular portion of the right ventricular apex. An aortogram showed the aneurysmatic
origin of the tunnel (Fig 2). The left coronary artery
originated separately and divided normally into its two
branches. The left anterior descending artery ran parallel
to the tunnel. A dominant right coronary artery was
present. A small patent ductus arteriosus also was seen.
The pulmonary artery pressure was 70 mm Hg, and the
Accepted for publication May 18, 1998.
Address reprint requests to Dr Vargas, San Martı́n 1353, (1828)Banfield,
Buenos Aires, Argentina.
© 1998 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
Fig 1. Preoperative two-dimensional color Doppler echocardiographic evaluation. A huge tunnel (TUN) connected with the aorta
(AO) at a supravalvular level follows its course within the interventricular septum. An aneurysmal dilatation is observed at the aortic
end (SVI).
saturation was 80%. The pulmonary-to-systemic flow
ratio was 2:1.
At operation, the patient was prepared for bypass
and the ductus was ligated. From the external inspection,
it was not possible to distinguish the tunnel from the
surrounding myocardium, except by the presence of a
continuous thrill located to the right of the left anterior
descending artery. Both right and left coronary arteries
were normal for a pattern of right coronary dominance.
Although the aneurysmatic origin of the tunnel was
Fig 2. A supravalvular aortogram (AO) shows the tunnel channeling its way toward the right ventricular apex. It is dilated at the
aortic origin (T). The left coronary artery (arrow) originates below
the entrance of the tunnel. This runs parallel to the left descending
coronary artery.
PII S0003-4975(98)00927-8
Ann Thorac Surg
Fig 3. Surgical technique. (A) Operative view. The
pulmonary artery is retracted. An aneurysmal dilatation is observed at aortic origin (arrow). The
dashed line indicates the site of opening of the tunnel. (B) The tunnel connected proximally with the
aorta (top arrow) and distally with the right
ventricle, close to the trabecular portion (bottom
arrow). (C) Patch closure of both the proximal and
distal openings from inside the tunnel. (D) The external incision in the myocardium was closed with
interrupted mattress sutures including both patches.
evident at the aortic level, it rapidly disappeared into the
underlying myocardium. Under deep hypothermia, the
aorta was cross-clamped. When cardiac chambers were
emptied, an area of myocardium along the left anterior
descending artery collapsed. Once opened, this showed
(Fig 3) an intramural canal running within the interventricular septum connecting both the aorta and the
right ventricle, opening midway between the septal band
and the trabeculae of the apex. A “J”-shaped aortotomy
was performed, disclosing the aneurysmatic opening
of the tunnel located above the upper margin of the left
sinus of Valsalva with a ridge interposed between
both. This was the external outpouching observed in the
aorta. The left coronary ostium was close to the margin of
the aortic entrance of the tunnel. From its aneurysmatic
origin, this chamber tunneled its way into the right
ventricle. The aortic valve leaflets were normal in appearance. Repair of the malformation through the aorta
seemed inadvisable, because distortion of the left coronary ostium could result. Both a Dacron patch to the
aortic end and a Dacron patch to the ventricular end of
the tunnel were sutured from inside the tunnel. Finally
both patches were sutured together, including the
surrounding myocardium, with interrupted mattress
sutures. The patient came off bypass uneventfully.
He was discharged a week later with no murmurs
and no medication. A two-dimensional color echocardiographic evaluation performed a month later showed
absence of aortico–right ventricular communication
through the tunnel. Five years later he remained
There are few reports on aortico–right ventricular tunnel
in the literature [1– 4]. Two such cases with operation
have been reported. Bharati and associates [3] described
a postmortem specimen in which a tunnel arising
above the right sinus of Valsalva connected with the
right ventricle. They found a supravalvular ridge above
the right sinus of Valsalva, which was considered as a
part of the malformation. As in our case it constituted a
border dividing the sinus of Valsalva itself from the
aneurysmal dilatation of the aorta. In their report, the
tunnel entered the right ventricle below the parietal
band. In a patient who was operated on successfully,
Saylam and colleagues [1] described a tunnel originating
above the left coronary cusp, which opened at the level
of the septal band of the right ventricle. Both ends
were closed with interrupted sutures. In a case with
operation reported by Westaby and Archer [2], the entrance of the tunnel was closed through the aorta. In our
patient, the diagnosis was suspected preoperatively on
the basis of the echocardiographic and angiographic
Differential diagnosis with ruptured aneurysm of
the sinus of Valsalva can be made based on the patient’s
history and angiographic findings. A coronary artery
Ann Thorac Surg
fistula was ruled out because the coronary arteries
originated and were distributed normally and independently from the tunnel. As in the case described by
Bharati and associates [3], our patient presented cardiac
failure early in life. Although we were tempted to repair
the malformation by closing the aortic origin of the
tunnel through the aortotomy, it seemed risky because
the sutures could distort the left coronary ostium.
Occluding the tunnel both at the proximal and distal
openings from inside, the tunnel itself appeared to be
a safer approach. Echocardiographic and angiographic
evaluation should provide a proper diagnosis of this rare
1. Saylam A, Tuncali T, Hazler C, Aytac A. Aortico–right ventricular tunnel. A new concept in congenital cardiac malformation. Ann Thorac Surg 1974;18:634–7.
2. Westaby S, Archer N. Aortico–right ventricular tunnel. Ann
Thorac Surg 1992;53:1107–9.
3. Bharati S, Lev M, Cassels DE. Aortico–right ventricular tunnel. Chest 1973;63:198 –202.
4. Freedom RM. Congenital valvular regurgitation. In: Freedom
RM, Benson LN, Smallhorn JF, eds. Neonatal heart disease.
Toronto: Springer-Verlag, 1992:679– 81.
Murphy’s Law in Cardiac Surgery
Charlotte Fischer, MD, Werner Kenn, MD, and
Rolf-Edgar Silber, MD
Departments of Cardiothoracic Surgery and Radiology,
University of Würzburg, Würzburg, Germany
We report the case of a 41-year-old man who underwent
heart transplantation after suffering from aortic dissection during the implantation of a biventricular assist
device for heart failure after coronary artery bypass
grafting. The biventricular assist device had to be operated by hand for 10 hours because of a technical defect. In
the end perseverance won out and the patient is now
doing well at 2.5 years of follow-up.
(Ann Thorac Surg 1998;66:1795–7)
© 1998 by The Society of Thoracic Surgeons
ortic dissection still is a severe problem with a poor
prognosis in spite of all technical improvements
[1–3]. Rare cases of aortic dissection after heart transplantation have been reported, most of them with a fatal
ending [4 –7]. Here we describe a case of heart transplantation performed after replacement of the ascending
Accepted for publication May 15, 1998.
Address reprint requests to Dr Fischer, Department of Cardiothoracic
Surgery, University of Würzburg, Josef-Schneider-Str 6, Bau 28, D-97080
Würzburg, Germany.
© 1998 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
The 41-year-old patient suffered from acute myocardial
infarction in November 1994. Although he had various
risk factors such as hypertension, increased cholesterol
serum levels, and heavy cigarette smoking, he was never
symptomatic before. In January 1995 he underwent cardiac catheterization because of persisting angina pectoris. Extensive coronary artery disease was diagnosed with
diffuse distal disease and significant stenoses of the left
main coronary artery, the left anterior descending artery,
and the circumflex artery. Bad ventricular function was
evident, with an ejection fraction of 0.15 and a left
ventricular end-diastolic pressure of 21 mm Hg.
We realized that this patient was a candidate for
transplantation, yet unstable angina led us to try coronary artery bypass grafting on February 3 to at least gain
some time. Because of hemodynamic instability at induction of anesthesia we had to establish cardiopulmonary
bypass (CPB) as fast as possible. We therefore decided
against the mammary artery and bypassed the left anterior descending and circumflex arteries with saphenous
vein grafts. After a cross-clamp time of 30 minutes and 60
minutes of reperfusion, CPB could only be discontinued
with support by intraaortic balloon counterpulsation
(model 64625; Datascope, Bensheim, Germany) plus catecholamines in moderate doses.
During the next 48 hours a change for the worse was
evident. Continuing low cardiac output in spite of intraaortic balloon pumping and extended catecholamine
support was the indication for application of a ventricular
assist device to the young man on February 5.
We established CPB by femoral cannulation without
difficulties. Five minutes after the beginning of CPB the
arterial line pressure tremendously increased, and CPB
stopped because of retrograde aortic dissection. Finally
the aorta ruptured in that area, where the saphenous vein
grafts had been anastomosed 2 days before. At that
moment the pupils turned wide. Instantly we changed
arterial cannulation into the true channel of the dissected
ascending aorta and restarted CPB. The pupils contracted. During a total circulatory arrest time of 20 minutes at 20°C the ascending aorta was replaced by a size 27
Dacron tube (Meadox, Ratingen, Germany). Arterial cannulation was reinserted into the prosthesis, and during
rewarming the vein grafts were reanastomosed.
As far as we could assess intraoperatively, no major or
irreversible damage had happened to the patient during
this episode. In particular, the pupils were neither constricted nor dilated and were reacting promptly. We
therefore went on with the implantation of the biventricular assist device, yet the situation was so unusual
that we could not decide on irreversible cannulation.
Instead we wanted to maintain even the smallest chance
of recovery and weaning. At that time we did not even
know if we would really perform transplantation in
someone suffering from aortic dissection. Cannulation
was performed into the right atrium and the left atrium
with a 50F bent Jostra Bioline HUKV 50-H (Jostra, Hirrlingen, Germany) in each and into the pulmonary artery
and the aortic prosthesis with a 51F Jostra Bioline HUKV
13-H in each. For the right ventricular assist device we
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