Remarkable symptoms of angina pectoris during exercise in a young girl were first treated with diltiazem 60 mg t.i.d. The history of the patient showed an operation on coarctatcio aortae 11 months after birth. Seven years later, she underwent a second operation for a re-implantation of the left main track (LMT) into the aortic root in the presence of Bland-White-Garland-Syndrome. In order to elucidate morphological aspects a heart catheterization was performed because of persistent and increasing symptoms. Figure 1 illustrates an unusual high re-implantation site of the LMT and in accordance with this; a LMT-bending of nearly 90° could be demonstrated. Intravascular ultrasound (IVUS) clearly visualized an additional compression of the LMT during every heart cycle at the bended site (Figures 2 and 3). After implantation of a paclitaxel eluting stent (DES; 3.0/8 mm), a normal angiographic aspect occurred (Figure 4). Three months later the patient was free of symptoms at rest and under stress echo conditions. A six months angiographic follow-up confirmed a perfect long-term result (Figure 5).  Figure 1. Aortic root with re-implanted LMT. Bending of LMT at the origin.  Figure 2. IVUS at the bent site of LMT, diastole.  Figure 3. IVUS at the bent site of LMT, systole.  Figure 4. After stent implantation.  Figure 5. Six months angiographic follow-up.

We suggest that the longitudinal growing of our patient was the main reason for the development of the bending at the origin of LMT. Those patients with symptoms of angina pectoris and with re-implanted coronary arteries should undergo angiographic evaluation along with IVUS. In the era of DES, a satisfying option for treatment is available with very promising long-term results.