We report the case of a 12-year-old girl; she had a medical history of FH like her brother with tendon xanthomas of the upper and lower extremities [Figure 1]. She was operated two years previously for aortic stenosis associated with mitral valve regurgitation grade 3 without coronary artery disease [Figure 2]. She had a Ross intervention with mitral annuloplasty with positive results. Currently, she was admitted in emergency for acute coronary syndrome with negative ST and positive troponin I with initially stable hemodynamic constants. A transthoracic echocardiography was done which showed a dilated left ventricle with an ejection fraction of 61%, mitral regurgitation grade 2, absence of aortic insufficiency, and a good functioning of a Contegra tube in pulmonary position. The patient was directly sent to the catheterization laboratory where angiography showed stenosis of the distal left main trunk, subocclusive stenosis of the proximal circumflex coronary, a stenosis of the second and distal parts of the interventricular coronary, and proximal subocclusive stenosis of the right coronary artery [Figure 3]; it also showed stenosis of both left and right subclavian arteries [Figure 4]. She was hospitalized in the surgical intensive care unit and antianginal treatment was initiated. Her hospital course was complicated by the deterioration of hemodynamic status with several outbreaks of left heart failure related to mitral regurgitation grade 3-4 with a low ejection fraction of 35%, requiring the introduction of vasoactive drugs in gradually high doses.
The patient was operated and three aortocoronary grafts using the two saphenous veins taken at the thigh because of the presence of stenosis of subclavian arteries, in addition to the replacement of the mitral valve by a mechanical prosthesis. The postoperative course and medium-term follow-up were excellent with improved hemodynamic status and the disappearance of angina and dyspnea.