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Proximal tubular aortopulmonary window in an adult - A diagnostic dilemma solved by cardiac computed tomographic angiography

  • Author Footnotes
    1 Resham Singh and Vineeta Ojha contributed equally and share first authorship.
    Resham Singh
    Footnotes
    1 Resham Singh and Vineeta Ojha contributed equally and share first authorship.
    Affiliations
    Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
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  • Author Footnotes
    1 Resham Singh and Vineeta Ojha contributed equally and share first authorship.
    Vineeta Ojha
    Footnotes
    1 Resham Singh and Vineeta Ojha contributed equally and share first authorship.
    Affiliations
    Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
    Search for articles by this author
  • Sravan Nagulakonda
    Affiliations
    Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
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  • Amarinder Singh Malhi
    Affiliations
    Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
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  • Ankur Handa
    Affiliations
    Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India
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  • Sanjeev Kumar
    Correspondence
    Corresponding author.
    Affiliations
    Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
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  • Author Footnotes
    1 Resham Singh and Vineeta Ojha contributed equally and share first authorship.
Published:April 03, 2022DOI:https://doi.org/10.1016/j.jcct.2022.03.007
      A 35-year-old manpresented with multiple episodes of syncope for last one year. He underwent transthoracic echocardiography, which raised the possibility of ruptured sinus of Valsalva into the pulmonary trunk (PT) and mild aortic regurgitation. He was subsequently referred for cardiac computed tomographic angiography (CTA) which showed a dilated tubular 2cm long channel (black ∗) connecting aortic root with PT,which was joining the PT 2.8 cm above the pulmonic valve (Fig. 1A–C). The left coronary artery (white →) was arising from the base of the channel at the aortic end (Fig. 1C). The diameter of the channel was ∼20 mm at the aortic end and 14.8 mm at the PT end. It was traversing superiorly from the aortic end towards the pulmonary end. There was no significant narrowing, thrombus or calcification. Additionally, a 16 ​× ​7mm out-pouching was seen arising from the right medial wall of the main pulmonary artery (Black →Fig. 1D).The differentials of intrapericardial communication at the level of aortic sinus include ruptured sinus of Valsalva, aortopulmonary window and coronary artery fistula. Since there was no aneurysm and the communication was tubular, it was unlikely to be ruptured sinus of Valsalva. Also the channel was not in line with any coronary artery, making the diagnosis of coronary artery fistula unlikely. Separate semilunar valves of the aorta and PT (white and yellow arrows in Fig. 1D, respectively) were seen clearly. Hence, the final diagnosis was a tubular aortopulmonary window or more accurately, aortopulmonary tunnel. On subsequent evaluation, the patient was found to have irreversible pulmonary arterial hypertension (PAH) which is why he was not a good candidate for surgical or endovascular intervention. He is being managed medically for the PAH.

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