Aortic Coronary Anomaly Causing Acute Myocardial Infarction in an Adolescent: Emergency Percutaneous Revascularization as a Bridge to Surgical Repair

Abstract Background : Anomalous aortic origin of the left main coronary artery (AAOCA) with an interarterial course is a rare but high-risk congenital anomaly, predisposing adolescents to acute myocardial infarction (AMI) and sudden cardiac death during exertion. The optimal management of AAOCA-related AMI with cardiogenic shock in pediatric patients remains poorly defined, with no established consensus in current guidelines. This case highlights the novel strategy of emergency percutaneous coronary intervention (PCI) as a critical bridging therapy to stabilize hemodynamics prior to definitive surgical repair. Case presentation : A previously healthy 14-year-old male with a history of exercise-induced chest tightness presented with recurrent anginal symptoms, progressive dyspnea, and hemodynamic collapse following vigorous physical activity. Electrocardiography revealed acute ischemic changes, and laboratory tests showed severe lactic acidosis. Emergency coronary angiography identified a slit-like ostial stenosis of the left main coronary artery arising anomalously from the right coronary sinus with an interarterial course. Given the critical instability and impending circulatory failure, emergency stenting was performed, achieving immediate restoration of TIMI 3 flow and rapid hemodynamic improvement. However, at one-year follow-up, the patient developed severe in-stent restenosis with stent malapposition due to persistent mechanical compression from the anomalous anatomy, necessitating subsequent coronary artery bypass grafting. Conclusion : This case demonstrates that emergency PCI can serve as an effective and life-saving bridge to stabilize adolescents with AAOCA-related AMI and cardiogenic shock, enabling timely surgical correction. However, the late occurrence of stent failure underscores the biomechanical limitations of percutaneous intervention in this setting and reinforces that surgery remains the definitive treatment. This approach offers a practical management algorithm for this rare and high-risk emergency scenario.