Cardiogenic shock in an 8-year-old child secondary to anomalous coronary origin and course: a case report on the value of coronary computed tomography angiography and cardiac magnetic resonance

Abstract

Cardiogenic shock is a severe disease caused by primary failure of cardiac function. Myocardial infarction is the most common cause of cardiogenic shock. It is common in adults but rare in children. An anomalous left coronary artery originating from the right sinus of Valsalva with an inter-arterial course between the pulmonary trunk and aortic root is a rare isolated congenital anomaly, with a high risk of sudden cardiac death, particularly in the context of exercise. Coronary computed tomography angiography (CCTA) allows non-invasive evaluation of congenital coronary anomalies in adults and children, including the location of the anomalous origin, details of the intramural segment, and the angle between the ostium and proximal segment. However, there are few data describing the role of cardiac magnetic resonance (CMR) children because of long scanning time and several contraindications. This case report describes an 8-year-old male child with cardiogenic shock caused by acute myocardial infarction. CCTA revealed a left coronary artery arising from the right sinus of Valsalva with inter-arterial course, and a moderately narrowed mid-portion of left main coronary artery, while CMR indicated myocardial infarction which located in left ventricular anterior, septal and lateral wall, together with intramyocardial hemorrhage (IMH) and microvascular obstruction (MVO). Combined application of CCTA and CMR could show coronary artery anomalies, myocardial viability, tissue characteristics, and would play an important role in the diagnosis and assessment.

Keywords: Cardiogenic shock; cardiac magnetic resonance (CMR); congenital coronary anomaly; coronary computed tomography angiography (CCTA).

Figure 1

Volume rendering technique and curved planar reformat view demonstrate narrowing (white arrow in A,B) of mid-portion of left main coronary artery, the acute angle at the ostium (black arrow in B) and the intramural segment (white arrow in B).

Figure 2

Cardiac magnetic resonance demonstrates myocardial edema (white arrowhead in A) and intramyocardial hemorrhage (white arrow in A) in T2WI,perfusion defect (red arrow in B) in rest myocardial perfusion, microvascular obstruction in early (red arrowhead in C) and late (yellow arrow in D) gadolinium enhancement sequence.

Figure 3

Coronary angiography demonstrates anomalous origin of left coronary artery (green arrow) and stenosis of mid-portion of left main coronary artery (yellow arrow).

Figure S1

Electrocardiogram demonstrates sinus tachycardia with abnormal Q wave (I, AVL and V1-V3 leads).

Figure S2

Bedside chest radiograph demonstrates multiple patchy bilateral opacifications, more pronounced in the perihilar segments.

Figure S3

2D M-mode echocardiography demonstrates normal left ventricular volume and wall thickness, but mildly reduced left ventricular ejection fraction (49%).