CASE REPORT Aortico-left ventricular tunnel: a rare congenital cardiac anomaly in an adult Nimish Rai & Avinash Sharma & Vinay Kulkarni & Ram Godeshwar & Pankaj Harkut Received: 28 December 2009 / Revised: 24 February 2010 / Accepted: 8 July 2010 / Published online: 13 August 2010 # Indian Association of Cardiovascular-Thoracic Surgeons 2010 Abstract Aortico Left Ventricular Tunnel (ALVT) is a rare congenital anomaly. It presents as an asymptomatic murmur to severe Aortic Regurgitation (AR) and heart failure. Most of the patients have heart failure in first year of life. Patient rarely present beyond second decade of life. Here we report a 42 year male with unusual type of ALVT, who presented with heart failure and conduction disturbances. Keywords Regurgitation . Rupture . Left ventricular Introduction Aortico Left Ventricular Tunnel (ALVT) is a short abnormal pathway that begins as an aneurysmal dilatation of aortic root and upper portion of right sinus of Valsalva (rarely the left), just to the left of the orifice of right coronary artery. The defect then traverses through the upper end of the ventricular septum to open in the LV cavity. It is a rare congenital anomaly of heart with of an incidence ranging from 0.1–0.5%. Case report A 42 year male presented with dyspnea on minimal exertion and chest pain since 1 month. Patient was diagnosed as a case of aortic valve disease with aortic regurgitation since 7 years. On clinical examination, patient had elevated jugular venous pressure, regular pulse, bradycardia (40/min), apex pulse deficit, resting blood pressure 160/50 mmHg and pedal edema. A precordial left parasternal systolic thrill, ejection systolic murmur and early diastolic murmur was present at aortic area. Electrocardiogram showed bradycardia (Rate of around 40/min) and Complete heart block with wide QRS Complex with some ectopics and LV hypertrophy. X-ray chest revealed Cardiomegaly. Transthoracic Echocardiogra- phy diagnosed a tunnel in the Interventricular Septum (IVS) communicating aorta from above the right coronary sinus to left ventricular cavity at mid septum (Fig. 1), moderate to severe valvular aortic regurgitation, dilated Left Ventricle (LV) and left atrium with ejection fraction of 20%. Our plan of management was temporary pace maker insertion and cardiac catheterization followed by surgical correction. Cardiac catheterization confirmed echocardiographic find- ings and demonstrated calcified wall of tunnel. In the operating room, after institution of routine invasive and non-invasive monitoring and induction of anaesthesia, midline sternotomy was performed. After systemic heparinisation, aortic and two stage venous cannulation was achieved. Following establishment of cardiopulmonary bypass, aorta was cross clamped and cardiac arrest was achieved via retrograde and direct antegrade cardioplegia. Moderate hypothermia was main- tained on bypass. On opening the aorta, a 0.8 cm opening was present in right coronary sinus to the left of right coronary ostia (Fig. 2). Aortic valve was thinned out and noncoapting. Left ventricular opening of tunnel was noted N. Rai : A. Sharma : R. Godeshwar : P. Harkut Department of Cardio Thoracic and Vascular Surgery, Care Hospital, Nagpur, India A. Sharma (*) Care Hospital, 3, Farmland, Panchsheel Square Ramdaspeth, Nagpur 440010 Maharashtra, India e-mail: avirai32@gmail.com V. Kulkarni Department of Anesthesia, Care Hospital, Nagpur, India Indian J Thorac Cardiovasc Surg (2010) 26:216–218 DOI 10.1007/s12055-010-0038-4