Cardiac strangulation is a rare and potentially deadly complication of epicardial pacemaker implantation. A young boy presenting with chest pain and tiredness almost 7 years after pacemaker implantation was found to have cardiac strangulation. Literature review revealed 22 cases reported to date with a worrying rise in the number of reports over the past 3 years. Strangulation is associated with implantation of leads at a young age and appears to be related to somatic growth. Serial assessment with chest X-ray and echocardiogram is recommended, at least until full adult growth is attained with further coronary artery imaging reserved for symptoms or suspicious echocardiographic findings. If cardiac strangulation is diagnosed prompt replacement of the offending system is needed.

A 12-year-old boy with intermittent syncope associated with exercise. Exercise stress testing suggested myocardial ischemia and 2D echocardiography failed to confirm antegrade flow in the left main stem. Advanced imaging techniques including cardiac-gated computed tomography angiography and stress cardiac magnetic resonance imaging were falsely reassuring. Cardiac catheterization demonstrated left coronary artery ostial atresia with a good caliber left coronary system supplied by generous collaterals from the right coronary artery. The patient underwent successful coronary artery bypass grafting.