A hidden coronary cause of cardiogenic shock after exercise in a child: a case report

Malignant left main coronary artery (LMCA) anomalies are rare but potentially fatal congenital defects that may cause myocardial ischemia or sudden cardiac death during exertion, even in otherwise healthy children. Early recognition and timely intervention are crucial to prevent catastrophic outcomes. We report a 10-year-old boy who developed chest pain and dyspnea while exercising, followed by pulmonary edema and refractory cardiogenic shock. Coronary angiography at the referring hospital showed a critical proximal LMCA lesion, and coronary computed tomography (CT) angiography at our centre confirmed a malignant LMCA arising high from the aortic root with an interarterial and intramural course. The electrocardiogram showed persistent ST-segment elevation. Despite maximal medical therapy, emergent central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was required. After stabilization, the LMCA was surgically reimplanted to its anatomical position. The patient was weaned from ECMO in the operating room and recovered, with normalization of cardiac enzymes and the electrocardiogram. He was discharged on day 13 and, two months after discharge, underwent elective coronary stenting for a residual LMCA narrowing. This case highlights the importance of maintaining a high index of suspicion for malignant LMCA anomalies in children presenting with exertional chest pain. Prompt hemodynamic support with ECMO and timely surgical correction can be lifesaving in these rare but high-risk conditions. Not applicable.