Discussion

Aorto-left ventricular tunnel can present in various ways, with symptoms in the infantile period often dependent on the size and location of the tunnel. ^{Reference Wong, Amelia, Mohd Zain and Sayuti3} Infants and children with large tunnels may develop congestive heart failure, exhibiting signs such as tachypnoea, poor feeding, and failure to thrive. Some patients may remain asymptomatic and reach the second decade of life without developing heart failure. ^{Reference Bjork and Crafoord1–Reference Wong, Amelia, Mohd Zain and Sayuti3}

The diagnosis of aorto-left ventricular tunnel typically involves a combination of clinical evaluation, non-invasive imaging techniques, and cardiac catheterisation. Prenatal diagnosis can be made with fetal echocardiography after 18 weeks of gestation. ^{Reference Chowdhury, Anderson and George4} Aortic left ventricular tunnels originating from the left coronary sinus can be challenging to diagnose and may be mistaken for aortic root dilation and ascending aortic aneurysms. While echocardiography can facilitate diagnosis, other imaging modalities may also be necessary. ^{Reference Yildirim, Erek, Uslu, Saygili and Karaagac5} Differential diagnoses include aortic regurgitation, Valsalva fistula, common arterial trunk, aortopulmonary window, and coronary ventricular fistula. Echocardiography, cardiac MRI, or CT scans might be required. ^{Reference Staniczek, Michalczyk, Stojko and Wloch6} Therefore, we employed all these modalities to ensure accurate diagnosis. While conventional angiography was employed to complement transthoracic echocardiography, it proved less efficacious in delineating aorto-left ventricular tunnel. Similarly, cMRI did not demonstrate significant success in this regard. In our article, transthoracic echocardiography is advocated as a more demonstrative imaging modality.

The management of aorto-left ventricular tunnel hinges on several factors, including the patient’s age, symptoms, and the size and location of the tunnel. Staniczek et al. suggested that early diagnosis and intervention are associated with more favourable outcomes, with many patients achieving normal cardiac function following successful tunnel closure. ^{Reference Staniczek, Michalczyk, Stojko and Wloch6,Reference Sathe, Tomar and Krasemann7} Our patient underwent surgery promptly upon presentation, and the intervention occurred before the left ventricular functions deteriorated.

Mueller et al. described a technique that approaches aorto-left ventricular tunnel through a transverse aortotomy and a transverse right ventricular infundibulotomy. They create an incision in the left lateral free wall of the tunnel, providing access for surgical correction. ^{Reference Mueller, Dave and Prêtre8} In contrast, we preferred advancing the aortotomy towards the aneurysm within the tunnel, enabling clear visualisation of the ventricular entry of the tunnel. This approach facilitated the closure of the tunnel’s entrance from the aortic side and the exit from the ventricular side using a single patch. Long-term follow-up is essential to monitor for potential residual shunts, valve regurgitation, or other complications.

While surgical closure has traditionally been the gold standard, transcatheter techniques have emerged as a promising alternative. Ongoing research and interdisciplinary collaboration in the field of paediatric cardiology will contribute to a better understanding of aorto-left ventricular tunnel and the refinement of therapeutic strategies, ultimately enhancing the quality of life for individuals affected by this condition. In asymptomatic or older children, transcatheter closure using occluder devices has emerged as a less invasive alternative, especially for smaller tunnels. ^{Reference Sathe, Tomar and Krasemann7} Long-term follow-up is crucial to monitor for potential residual shunts, valve regurgitation, or other complications.