Percutaneous Coronary Intervention in an 8-Month-Old Infant for Ostial Stenosis of a Reimplanted Left Main Coronary Artery

Ostial stenosis of reimplanted left main coronary artery and supravalvular pulmonary stenosis: a case report of two complications of surgery for anomalous left coronary artery from the pulmonary artery

Background

Anomalous origin of the coronary artery from the pulmonary artery (ALCAPA) is a rare congenital disease. Surgical re-implantation of the left main coronary artery (LMCA) to the aorta is a definitive treatment with a good prognosis.

Case summary

A 9-year-old boy was admitted with a complaint of exertional chest pain and dyspnoea. At 13 months of age, he was diagnosed to have ALCAPA as a workup of severe left ventricular systolic dysfunction and underwent coronary re-implantation of ALCAPA. Coronary angiogram displayed the high takeoff of re-implanted LMCA with significant ostial stenosis, and echocardiogram showed significant supravalvular pulmonary stenosis (SVPS) with a peak gradient of 74 mmHg. After a multidisciplinary team discussion, he underwent percutaneous coronary intervention with stenting to ostial LMCA. On follow-up, he was asymptomatic and a cardiac computed tomography scan showed a patent stent in LMCA with an under-expanded area in the mid-segment. The proximal part of the LMCA stent was located very close to the stenotic segment of the main pulmonary artery making it a high risk for balloon angioplasty. The surgical intervention of SVPS is delayed to allow the somatic growth of the patient.

Discussion

Percutaneous coronary intervention in re-implanted LMCA is a feasible option. If stenosis of re-implanted LMCA is accompanied by SVPS, the latter can be best treated surgically and staged to decrease the operative risk. Our case also demonstrates the importance of long-term follow-up of post-operative complications of patients with ALCAPA.

Intravascular ultrasound-guided stent implantation in reimplanted left main coronary artery of a 15-year-old child: a case report

BACKGROUND

Only a few cases have been reported about clinical value of percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS) in patients with stenosis of a re-implanted left main coronary artery (LMCA).

CASE SUMMARY

We herein report a rare case of restenosis after direct reimplantation of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in a 15-year-old girl. At the first evaluation, she had mildly reduced systolic dysfunction with left ventricular ejection fraction of 47%. Three months after surgical repair, the patient developed recurrent precordial pain. Consequent imaging tests and IVUS revealed a restenosis of the LMCA characterized as an attenuated plaque with a large plaque burden. A drug-eluting stent was implanted with IVUS guidance. Follow-up revealed a patent LMCA and preserved systolic function.

DISCUSSION

The current case demonstrated that IVUS-guided PCI can be feasible in the treatment of coronary artery stenosis after repair of an ALCAPA. Further study is needed to explore the pathophysiological mechanism of this condition and the clinical value of PCI and IVUS in patients with stenosis of the LMCA.

Intravascular ultrasound use for stent optimization during percutaneous coronary intervention in a toddler with post-surgical stenosis after coronary reimplantation for ALCAPA

Percutaneous coronary intervention (PCI) is an uncommon procedure in the pediatric population, and the use of intravascular ultrasound (IVUS) to guide stent optimization in this setting is not well described. We present a case of a 22-month old female who developed left main coronary stenosis following surgical correction of anomalous left coronary artery from the pulmonary artery (ALCAPA). PCI was pursued, and with the use of IVUS, stent placement was determined to be optimal. Given the limited data on the use of IVUS in PCI for children, we discuss the unique applications of IVUS, drug-eluting stents, and future clinical concerns following management of post-surgical stenosis following ALCAPA repair. 〈Learning objective: Percutaneous coronary intervention is a rare procedure in the pediatric population, and the use of intravascular ultrasound to optimize stent placement is not well described in this setting. Intravascular ultrasound may allow for more precise stent placement and may be useful during acute and long-term management of pediatric patients undergoing percutaneous coronary intervention.〉.