The patient with an aorto–left ventricular tunnel, mildly depressed left ventricular function, and mild aortic insufficiency was brought to the operating room for definitive repair on the sixth day of life. After the initiation of cardiopulmonary bypass and the induction of cardioplegic arrest, the ascending aorta was transected. A careful inspection of the aortic valve, the right coronary artery, and the orifice of the aorto–left ventricular tunnel was performed. For enhanced intraoperative visualisation, we employed a 5-mm 0° rigid endoscope (Hopkins II; Karl Storz, Tuttlingen, Germany), which provided high-resolution, magnified views of the intracardiac anatomy (Figure 1). The tunnel was closed using an autologous pericardial patch. After the aortic cross-clamp was removed, the coronary arteries were well perfused. Postoperative echocardiography revealed good left ventricle function, trivial aortic insufficiency, and no residual shunt.

Figure 1.

Endoscopic view of the aorto-left ventricular tunnel. ( a ) Aorto-left ventricular tunnel, ( b ) the coronary probe inserted into the right coronary artery, ( c ) the tunnel closed with an autologous pericardial patch. Ao-LV = aorta-left ventricle; RCA = right coronary artery.

Surgical repair of an aorto–left ventricular tunnel in neonates presents significant technical challenges due to the minute size and intricate spatial relationships of the involved anatomical structures. ^{Reference Nakamura, Miyaji, Yoshii, Ootomo and Kimura1} The aortic leaflet, the orifice of the right coronary artery, and the aorto–left ventricular tunnel are all confined within a very small and compact region. As such, any distortion of the aortic annulus or inadvertent impingement on the coronary ostium during patch closure may lead to severe hemodynamic compromise. Therefore, given the confined anatomy and the proximity of critical structures, achieving a successful and safe repair demands not only meticulous anatomical assessment and surgical precision but also adjunctive visualisation techniques that enhance spatial understanding and operative confidence.

The incorporation of a rigid endoscope proved exceptionally advantageous in this context. By providing a magnified and stable operative field, endoscopic visualisation allowed for accurate identification of the coronary ostia and precise delineation of the aortic annular margins. In contrast to conventional surgical loupes, the rigid endoscope offered superior magnification and depth of field, which proved critical for delineating the intricate spatial relationships among the aorto–left ventricular tunnel, aortic annulus, and right coronary ostium—structures that reside in a tightly confined and visually challenging operative field. This facilitated an anatomically faithful patch repair while preserving the integrity of surrounding critical structures. Beyond its intraoperative utility, endoscopic technology offers broader benefits in the realm of congenital cardiac surgery, including enhanced visualisation, postoperative review, database creation, and educational value. ^{Reference Burke2,Reference Jacobs, Elliott and Anderson3}