511M. Ono et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) [510][511][512] Fig. 1. Pre-operative still images from echocardiogram and cardiac angiogram. Long-axis view of echocardiogram showing a tubular communication between the ascending aorta and the left ventricle (a), and showing massive regurgitate flow (b). Selective antegrade left ventricular outflow tract angiography in frontal projection demonstrates an aortico-left ventricular tunnel located left-lateral and posterior to the ascending aorta (c).Fig. 2. Intra-operative pictures as seen from the surgeon's view after cardiac arrest. (a) ALVT was located posteriorly to the ascending aorta. (b) The aortic orifices arose from the left aortic sinus. There was a fusion between the right and left aortic cusps. (c) After direct closure of the aortic orifice of AVLT, patency of the LCA was confirmed. (d) Tunnel obliteration was concomitantly performed. (ALVT, aortico-left ventricular tunnel; LCA, left coronary artery.)treatment. In most of the cases, the aortic orifice of the tunnel arose from or above the right coronary sinus, and the tunnel was located antero-laterally to the ascending aorta. However, our case demonstrated that the aortic orifice arose from the left coronary sinus and the tunnel lay postero-laterally to the ascending aorta. We could find only three reports in which the aortic orifice is opened from the left aortic sinus w5-7x. In this situation, incision of the tunnel is difficult and the tunnel should be closed through aortic incision.As for the operative technique, Serino and colleagues w8x report that closing the aortic defect by direct suture distorts the cusps by pulling them toward the weak aortic wall, which remains unsupported within the dilated aortic sinus. From this point of view, the patch technique is believed to reduce that risk. Our case demonstrated a slitlike opening at the aortic end with no valve distortion. Then, primary closure of the aortic orifice was performed in addition to plication (obliteration) of the tunnel. The short-term result is satisfactory, but late development of severe aortic regurgitation remains a matter of concern w9x. Careful observation is needed in this anomaly after the surgical repair.
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