Aorto-left ventricular tunnel: transcatheter closure using an amplatzer duct occluder device

Abstract

A ventricular tunnel is a congenital abnormal paravalvular pathway between the aortic root and the left ventricular cavity bypassing the aortic valve and not penetrating the septal musculature.1 This cardiac anomaly was first described by Levy et al in 1982.2 Surgical closure is usually the treatment of choice. We report the first transcatheter closure of an aorto-left ventricular tunnel using an Amplatzer patent ductus arteriosus (PDA) occluder device (AGA Medical Corporation, Golden Valley, Minnesota). • • • This case concerns a 14-yearold boy whose mother had an uncomplicated pregnancy and an uneventful delivery. The initial neonatal examination did not reveal any heart problems or any other anomalies and the child was discharged after 48 hours. A diastolic murmur was first heard at 7 years of age during a routine check and he was referred to our outpatient clinic where the clinical diagnosis of aortic regurgitation (AR) was made. The echocardiogram showed a bleb in the right coronary sinus of Valsalva just to the left of the origin of the right coronary artery. He was clinically well and asymptomatic. Catheterization was performed in 1993 and confirmed mild AR without evidence of aortic valve prolapse or aneurysm formation. Left ventricular function, coronary arteries, and aortic arch were normal. The child has been under annual review and has remained symptom-free, with the same signs of mild AR. During the last evaluation in March 1999, the echocardiogram showed left ventricular volume overload due to an aorto-left ventricular tunnel and mild AR, although the aortic valve appeared normal. Catheterization was repeated to confirm the diagnosis and consider transcatheter closure. Under general anesthesia and transesophageal echocardiography control, a rightand left-sided cardiac catheterization was performed using a 6Fr sheath in the right femoral vein, a 5Fr sheath in the right femoral artery, and a 5Fr sheath in the left femoral artery. Separate arterial access was used to allow delivery of the device and ensure freedom of coronary flow before deployment. The patient weighed 61.6 kg, and 50 IU/kg of heparin was administered at the beginning of the procedure. The transesophageal echocardiogram showed a normally functioning but volume loaded left ventricle with mild AR. The aorto-left ventricular tunnel was sized at approximately 9 mm at its maximal diameter. Normal right-sided left ventricular and aortic pressures and saturations were recorded. Using a 5Fr pigtail and a 5Fr multitrack catheters (NuMed, Inc., Hopkinton, New York), angiography of the left ventricle, ascending aorta, and coronary arteries was performed to evaluate the anatomy. This showed an aorto-left ventricular tunnel arising from the right coronary sinus of Valsalva, but separate from the right coronary artery, and which drained into the left ventricle. The aorto-left ventricular tunnel measured 6.1 mm at its maximum diameter with a “windsock” shape (Figure 1). A 6Fr Gensini catheter was easily passed through the aorto-left ventricular tunnel into the left ventricle; an exchange guidewire was then introduced and stabilized in the left ventricle. The catheter was then replaced by an 7Fr delivery sheath and dilator which was advanced over the exchange wire into the left ventricle through the aorto-left ventricular tunnel. The dilator was removed and the delivery sheath was deaired. The correct position was confirmed by an injection of radiopaque contrast. A 10/8-mm Amplatzer PDA occluder device (AGA Medical Corporation, Minnesota) was mounted on a delivery wire and introduced into the delivery sheath through a loading device, and then advanced into the left ventricle through the aorto-left ventricular tunnel under fluoroscopic control. The device flange From The Heart Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom. Dr. De Giovanni’s address is: The Heart Unit, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom. E-mail: degiovanni@cableinet.co.uk. Manuscript received November 9, 1999; revised manuscript received and accepted February 4, 2000. FIGURE 1. Anteroposterior projection: aorto-left ventricular tunnel angiography showing the “Windsock” shape.