pulmonary trunk A third “intermediate” trunk was discovered between the aorta and pulmonary trunk, anterior and slightly leftward of the aorta, arising from the left ventricle with a rudimentary valve of its own, and giving rise to the right PA In this case, no other cardiac anomalies existed The patient died at 4 years of age of intractable heart failure Pelletier described an almost identical case in 2009, in whom a successful repair was performed.88 In both these cases the presence of a third arterial trunk was an isolated anomaly, in the setting of an otherwise normal heart A more recent report by Tingo87 described a unique case in which three arterial trunks arose entirely from the right ventricle, resulting in a “triple-outlet right ventricle” with a posterior malalignment VSD and a type b interruption of the aortic arch Similar to the two previously published cases, the intermediate trunk gave rise only to the right PA The patient underwent reimplantation of the right PA into the main PA, aortic arch repair, and banding of the main PA but succumbed to infection at 6 months of age Annotated References Anderson RH, Chaudhry B, Mohun TJ, et al Normal and abnormal development of the intrapericardial arterial trunks in humans and mice Cardiovasc Res 2012;95(1):108–115 This article provides objective evidence of mechanisms leading to AP window closure in the developing intrapericardial arterial trunks and offers insights to the formation of AP window and its variants Barnes ME, Mitchell ME, Tweddell J Aortopulmonary window Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2011;14(1):67–74 This is a relatively large study describing contemporary approach and outcomes of surgical repair of AP window and its variants Anderson RH, Cook A, Brown NA, et al Development of the outflow tracts with reference to aortopulmonary windows and aortoventricular tunnels Cardiol Young 2010;20(suppl 3):92–99 This is a comprehensive review providing insights into the embryology and anatomy of aortopulmonary windows and aortoventricular tunnels Martins JD, Sherwood MC, Mayer JE Jr, Keane JF Aortico-left ventricular tunnel: 35-year experience J Am Coll Cardiol 2004;44(2):446– 450 Given the rare occurrence of aorto–left ventricular tunnels, this 35-year experience of 11 patients provides insights into the treatment and natural history of this lesion Horvath P, Balaji S, Skovranek S, et al Surgical treatment of aortico-left ventricular tunnel Eur J Cardiothorac Surg 1991;5(3):113–116 [discussion 117] This article describes the surgical experience of 13 patients with aorto–left ventricular tunnels Mild-moderate aortic regurgitation was noted in 2 out of 12 survivors during an intermediateterm follow-up Meldrum-Hanna W, Schroff R, Ross DN Aorticoleft ventricular tunnel: late follow-up Ann Thorac Surg 1986;42(3):304–306 Although a small number of patients with aorto– left ventricular tunnels were followed in this report (six patients), half of them needed aortic valve replacement in the long term, highlighting progression of aortic regurgitation after aorto– left ventricular tunnels are repaired