Ann Thorac Surg 1998;66:1793–5 CASE REPORT VARGAS ET AL AORTICO–RIGHT VENTRICULAR TUNNEL 1793 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 A 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. 0003-4975/98/$19.00 PII S0003-4975(98)00927-8 1794 CASE REPORT VARGAS ET AL AORTICO–RIGHT VENTRICULAR TUNNEL Ann Thorac Surg 1998;66:1793–5 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 asymptomatic. Comment 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 findings. 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 1998;66:1795–7 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 malformation. References 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 A 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 aorta. 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 CASE REPORT FISCHER ET AL MURPHY’S LAW 1795 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 0003-4975/98/$19.00 PII S0003-4975(98)00926-6