Case Report
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Aug 16, 2016; 4(8): 219-222
Published online Aug 16, 2016. doi: 10.12998/wjcc.v4.i8.219
Coronary artery occlusion after arterial switch operation in an asymptomatic 15-year-old boy
Ashish P Saini, Stephen E Cyran, Steven M Ettinger, Linda B Pauliks
Ashish P Saini, Stephen E Cyran, Linda B Pauliks, Division of Pediatric Cardiology, Department of Pediatrics, Penn State Hershey Medical College, Hershey, PA 17033, United States
Steven M Ettinger, Division of Cardiology, Heart and Vascular Institute, Penn State Hershey College of Medicine, Hershey, PA 17033, United States
Author contributions: Saini AP chart review, literature review, drafted manuscript, first author; Cyran SE review of the manuscript; Ettinger SM review of the manuscript; Pauliks LB conception, co-writing, review of manuscript.
Institutional review board statement: The following case report has been exempt from informed consent by our institutional review board.
Informed consent statement: Patient verbally agreed.
Conflict-of-interest statement: The authors have no conflicts of interest for this publication.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Linda B Pauliks, MD, MPH, Division of Pediatric Cardiology, Department of Pediatrics, Penn State Hershey Medical College, Mailbox HP14, 500 University Drive, Hershey, PA 17033, United States. lpauliks@hmc.psu.edu
Telephone: +1-717-5318674 Fax: +1-717-5310401
Received: February 20, 2016
Peer-review started: February 23, 2016
First decision: March 25, 2016
Revised: March 31, 2016
Accepted: May 31, 2016
Article in press: June 2, 2016
Published online: August 16, 2016
Processing time: 174 Days and 17.9 Hours
Abstract

A 15-year-old boy with transposition of the great arteries (TGA) and neonatal arterial switch operation (ASO) presented with complete occlusion of the left main coronary artery (LMCA). Intra-operatively, an intramural left coronary artery was identified. Therefore, since age 7 years he had a series of screening exercise stress tests. At 13 years old, he had 3 to 4 mm ST segment depression in the infero-lateral leads without symptoms. This progressed to 4.2 mm inferior ST segment depression at 15 years old with normal stress echocardiogram. Sestamibi myocardial perfusion scan and cardiac magnetic resonance imaging was inconclusive. Therefore, a coronary angiogram was obtained which showed complete occlusion of the LMCA with ample collateralization from the right coronary artery system. This was later confirmed on a computed tomogram (CT) angiogram, obtained in preparation of coronary artery bypass grafting. The case illustrates the difficulty of detecting coronary artery stenosis and occlusion in young patients with rich collateralization. Coronary CT angiogram and conventional angiography were the best imaging modalities to detect coronary anomalies in this adolescent with surgically corrected TGA. Screening CT angiography may be warranted for TGA patients, particularly for those with known coronary anomalies.

Keywords: Transposition of the great vessels; Arterial switch operation; Coronary angiography; Ergometry; Coronary occlusion

Core tip: In complete transposition of the great arteries (TGA), neonatal arterial switch operation offers excellent long term survival. Yet there can be late coronary artery complications. In this case, an asymptomatic teenager had an abnormal screening exercise-stress test leading to the identification of complete left coronary occlusion. This case illustrates how rich coronary collateralization can obscure even complete coronary occlusion. As such, young patients pose a unique diagnostic challenge. Coronary computed tomogram (CT) angiogram and conventional angiography were the best imaging modalities to detect the problem. Screening CT angiography may be warranted for TGA patients, particularly for those with known coronary anomalies.