Intravascular ultrasound-guided percutaneous treatment of late-presenting left anterior descending artery compression after penetrating cardiac trauma in a young adult: a case report

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Abstract Background Penetrating cardiac trauma is rare in adolescents, and late acute coronary syndrome after surgical repair, which narrows left anterior descending artery, is even rarer. Managing ischaemia from late coronary stenosis without underlying atherosclerosis is challenging. Multimodal imaging, including coronary computed tomography and intracoronary imaging, is crucial for guiding treatment. Case summary An 18-year-old male presented with recurrent chest pain. Two years after surgical repair of a penetrating left ventricular injury, a 12-lead electrocardiogram showed deep, symmetrical T-wave inversions in the anterolateral leads. Coronary angiography revealed a myocardial bridge and a significant stenosis in the mid left anterior descending artery (LAD). After recurrent symptoms, coronary computed tomography angiography demonstrated repair material surrounding the stenotic segment. Myocardial perfusion imaging showed a small fixed defect without reported reversibility. Intravascular ultrasound (IVUS) showed a minimum lumen area of 1.85 mm2 without an atherosclerotic phenotype. Following individualized Heart Team review favoring a percutaneous approach, a drug-eluting stent was implanted; the final minimum stent area was 4.83 mm2. At 1 month, exertional chest pain had markedly improved, biomarkers were normal, and the electrocardiogram was unchanged. Discussion This case may represent one of the initial documented instances of IVUS-guided percutaneous coronary intervention (PCI) for late LAD compression caused by mechanical factors, following pledget repair for penetrating cardiac trauma in a young patient. Multimodal imaging helped clarify the underlying mechanism of this non-atherosclerotic coronary lesion, and a multidisciplinary Heart Team approach directed the personalized treatment decision.