Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in a Pediatric Patient With Cardiac Allograft Vasculopathy

Cardiac allograft vasculopathy (CAV) is an immunologically-mediated phenomenon that occurs in up to 50% of patients surviving to 10 years post orthotopic heart transplant (OHT). While the pediatric subgroup of OHT recipients has a lower overall prevalence of CAV, prognosis is poor after development, with a 24% mortality within 2 years of diagnosis. Medical therapy, including statins, remains the mainstay of treatment. Diffuse intimal thickening often precludes coronary artery bypass grafting, while repeat OHT is associated with inferior outcomes including increased mortality. Percutaneous coronary intervention (PCI) is a therapeutic option for CAV with excellent initial success rates, but higher rates of major adverse cardiovascular events. Despite these challenges, PCI may be performed safely and can serve as a palliative bridge for repeat OHT. There is a paucity of data on PCI for CAV of the unprotected left main coronary artery (ULMCA). We report the case of a 13-year-old female with CAV involving the distal bifurcation of the ULMCA who underwent PCI with drug-eluting stents. While these cases are technically challenging, strategies that may predict success include an appropriately selected patient, use of predictive models for outcomes assessment, and operator expertise.