Postoperative Left Anterior Descending Artery Compression and Left Ventricular Thrombus Following the Repair of a Penetrating Right Ventricular Injury in an Adolescent: A Case Report

Penetrating cardiac trauma in adolescents is rare. Perioperative myocardial infarction secondary to surgical repair with subsequent left ventricular (LV) thrombus is even more so. A 16-year-old male sustained a stab wound to the left anterior chest. He collapsed and was brought to the emergency department by the family in a peri-arrest state. Emergency sternotomy revealed a right ventricular (RV) free wall laceration adjacent to the left anterior descending artery (LAD), repaired with pledgeted sutures. The LAD appeared patent intraoperatively. Postoperatively, ECG demonstrated new ST elevation, and transoesophageal echocardiography demonstrated new regional wall motion abnormalities. Coronary angiography showed mid-LAD occlusion, considered secondary to extraluminal compression from local postoperative tissue swelling and/or pledget tension. Stenting was not pursued, as extrinsic compression is unlikely to be relieved by percutaneous coronary intervention, and reoperation was considered high risk immediately post-sternotomy. Transthoracic echocardiography later revealed severe LV systolic dysfunction (ejection fraction of 29%) and a 1.5 × 1.0 cm apical thrombus. Anticoagulation with enoxaparin was initiated and transitioned to warfarin, together with guideline-directed heart failure therapy. The patient recovered and was discharged on day 18 after admission. Follow-up echocardiography was planned at three months to reassess function and thrombus resolution. This case illustrates survival following penetrating RV injury complicated by perioperative LAD occlusion and subsequent ischemic LV dysfunction with thrombus, highlighting anticoagulation and heart failure management challenges in an adolescent.