Percutaneous left main coronary artery stent for acute myocardial ischemia after repaired ALCAPA

Abstract

Percutaneous coronary artery stent angioplasty is rare in the pediatric population but can be a life-saving by rapidly reestablishing flow to an obstructed coronary artery. It is a technically challenging and high-risk procedure in infants and further limited by the need for future surgical intervention. We report of an infant with anomalous left coronary artery from the pulmonary artery who underwent acutely successful surgical reimplantation of the left coronary artery onto the ascending aorta. One month later, she developed acute myocardial ischemia and emergent catheterization diagnosed near-total occlusion of the left coronary artery. We implanted a 2.5 mm coronary stent in the left main coronary artery with reestablishment of flow. The patient's left ventricular systolic function recovered within 4 weeks and repeat angiography 3 months later showed complete normalization of the entire left coronary artery system. The patient weighed 3 kg and was < 6 weeks of age at the time of stent implantation which to our knowledge is the smallest and youngest reported patient to undergo coronary stent angioplasty. This case supports the feasibility of this procedure in infants as a temporizing solution to hemodynamic instability from myocardial ischemia due to coronary artery stenosis. The left ventricular systolic function remained normal at 7 months after stent placement and the patient was clinically well from a cardiac perspective.

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

“…Of the four previously reported cases, two reported no limitations in follow-up visits at age 6 and 7 years [ 5 , 6 ], though one case required surgical intervention for recurrent mitral regurgitation in the interim. The other two only reported follow-up data within one year post-PCI [ 3 , 4 ]. Instrumentation including wires, balloons, and stents used in the pediatric population are variable and in accordance with feasibility of procedure as well as preference of the interventionalist.…”

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: A Review

“…Some of the signs and symptoms the child could present with include Adult patients diagnosed with ALCAPA have less severe symptoms when compared to children because they are still providing their heart with enough oxygenated blood despite the LCA originating in the PA. The most common signs and symptoms for both adults and children are angina and dyspnea [3][4]8,[10][11][14][15][16]. It is important to recognize these signs and symptoms in patients so they can receive the necessary treatment.…”

“…Treatments for ALCAPA are focused on reestablishing a dual coronary system with oxygenated blood being provided to the heart utilizing the least invasive and least risky procedure [2][3][4]8,[10][11][12][14][15][16]. The majority of the correctional procedures revolve around the origin of the LCA.…”

“…Corrective surgery is a necessity for patients who have ALCAPA because of the high risk of myocardial ischemia and myocardial infarction, but an optimal technique has not been determined yet [2][3][4][10][11][12][14][15][16]. The most favored surgical option is direct reimplantation of the anomalous LCA from the pulmonary artery into the ascending aorta [2][3][4].…”

“…This method of correction is only viable if the patient's LCA is in close proximity to the ascending aorta. If the artery is not around the ascending aorta, then one of the other methods available must be employed [2][3][4]8,[10][11][12][14][15][16].…”