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

Abstract

Percutaneous coronary intervention (PCI) is a routine procedure undertaken in adult patients. In children, the procedure remains rare and challenging due to a multitude of factors including but not limited to complex congenital heart disease anatomy, catheter and stent to patient size mismatch, and lack of data for post-PCI antiplatelet therapy. We present a case of PCI in an 8-month-old infant with anomalous left coronary artery from pulmonary artery (ALCAPA) who developed severe ostial kinking of the left main coronary artery (LMCA) after surgical reimplantation of the anomalous coronary. A 3.5 × 8 mm Vision bare metal stent was successfully placed into the LMCA and postdilated with excellent results. Follow-up echocardiography at 6 months post-PCI demonstrated a patent stent with normal Doppler flow signals. Despite initial success, the infant developed severe heart failure and was listed for orthotopic heart transplantation at age 20 months, one year after PCI. Given the paucity of published data regarding PCI and outcomes in infants with ALCAPA after surgical reimplantation, we describe our case and present a review of the available literature.

Percutaneous coronary interventions in children with structurally normal hearts. Is there any place for stenting?

“…1 Available literature suggests that PCI is feasible from infancy to adolescence. [2][3][4][5][6][7][8] Data on PCI in children and adolescents remain limited. This refl ects not only the relative health of the younger patient population, but also the technical challenges inherent to these procedures in smaller patients.…”

“…10 Acute coronary syndromes in children and infants are rare and secondary to many causes such as arteritis (Takayasu, Kawasaki…), spontaneous coronary dissection, congenital aneurysms, metabolic disorders (some familial hypercholesterolemia, nephrotic syndromes...) and post-transplant coronary vasculopathy in some abnormal coronary origins. [1][2][3][4][5][6][7][8][10][11][12][13] Congenital heart diseases were excluded from this article, but they occupy an important part of the etiologies as the abnormal left coronary artery originating from the pulmonary artery 'ALCAPA' does which represent the congenital disorder that is most frequently seen in cause of pediatric myocardial infarction with Kawasaki's disease. 14 In normally structured heart, during childhood and adolescence, causes could be divided into systemic ones with secondary affection of coronary arteries (Kawasaki's disease, vasculitis, genetic diseases causing hypercoagulability, nephrotic syndromes, and familial hyperlipidemia) and/or loco-regional epicardial coronary artery abnormalities (myocarditis, drugs and substances causing coronary spasm, spontaneous dissection, severe myocardial bridging, accelerated atherosclerosis, tumoral and infective embolisms and hypertrophic cardiomyopathy).…”

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

“…We present a case of a 22-month-old-toddler with post-surgical stenosis following ALCAPA repair successfully treated with IVUSguided, DES placement during PCI. Post-operative coronary stenosis following ALCAPA repair is rare, with few cases described [2]. The physiologic basis of this complication is unclear, but is theorized to be due to excess traction on the vessel with resultant disruption of the vaso vasorum leading to vessel injury [2].…”

“…Although less common, other acquired causes include coronary dissection, transplant vasculopathy, and external compression [1]. Anomalous left coronary artery from the pulmonary artery (ALCAPA) represents approximately 0.4% of congenital heart defects [2], and patients generally present within the first few months of life with difficulties feeding and breathing. Treatment is surgical, and attempts to create a dual vessel system, eliminating coronary steal into the pulmonary artery.…”

“…Treatment is surgical, and attempts to create a dual vessel system, eliminating coronary steal into the pulmonary artery. Although rare, post-operative coronary obstruction is a known complication [2]. With rising attention to PCI in the pediatric population, it is imperative to determine the optimal imaging modalities in this setting.…”