IMAGES IN CARDIOLOGY
Snakelike Aortic Right Ventricular Tunnel With Anomalous Origin of Left Main Coronary Artery in an Adult Woman
Athanasios Bratsas, MD*, ,
Charalambos Vlachopoulos, MD*,
Grigoris Kotoulas, MD ,
Thomas Makris, MD and
Christodoulos Stefanadis, MD*
* First Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece
Department of Cardiology, Elena Venizelou General and Maternity Hospital, Athens, Greece
Department of Radiology, Kyanous Stauros Hospital, Athens, Greece
Manuscript received September 4, 2009;
accepted October 5, 2009.
A previously asymptomatic 31-year-old woman presented with dyspnea on exertion. After findings on transthoracic echocardiography of a dilated artery originating from the left coronary sinus (arrow, A) and an abnormal flow at the base of the right ventricle (RV) (arrows, B, Online Video 1), cardiac magnetic resonance imaging confirmed the suspected diagnosis of a large aortic right ventricular tunnel (ARVT) arising from the ascending aorta (Ao) (arrow, C), moving along the left atrioventricular and then mid-ventricular grooves, and ending in the base of the RV (arrows, D). Classic coronary angiography showed an anomalous origin of the left anterior descending (LAD) and left circumflex (LCX) arteries (E, Online Video 2) from the tortuous aneurysmal tunnel that was evident in its entire length with a snakelike appearance (arrow, F, Online Video 3). Computed tomography coronary angiography confirmed a very short left main coronary artery (LMCA) (G, Online Video 4) arising from the snakelike ARVT (arrow, H). The aortic right ventricular tunnel is a rare anomalous congenital extracardiac conduit and almost always is a pediatric cardiology condition.
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Transthoracic echocardiogram. Short axis view at the level of the mitral valve with slight angulation, showing a torturous dilated vessel that moves at the base of the heart, penetrates RV and ends in its cavity forming an aneurysm with a stenotic orifice indicated by the high velocity turbulent flow seen with color Doppler.
Coronary artery angiography (a). The dilated aorto-right ventricular tunnel (ARVT) is seen giving rise to left main coronary artery that divides to normal left anterior descending (LAD) and left circumflex (LCX) arteries.
Coronary artery angiography (b). The ARVT is seen in all its length with an aneurysmatic end emptying into right ventricle through a stenotic orifice causing turbulent flow.
Axial CT coronary angiography scan (cine view) with cranio-caudal orientation showing the ARVT, that arises from the ascending aorta, moves along left atrio-ventricular and then mid-ventricular groove and ends in the base of right ventricle.
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