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We report the spectacular case of a young patient who developed cardiogenic shock caused by significant stenosis of the left main stem 8 years after orthotopic cardiac transplantation. Immediate percutaneous coronary intervention was a life saving procedure. The report illustrates the importance of early coronary angiography for the clinical management of heart transplant patients in cardiogenic shock as a relevant differential diagnosis to acute rejection. Allograft vasculopathy can develop unexpectedly even after years of uncomplicated follow-up.

Stenting of unprotected left main stem stenosis in cardiogenic shock after orthotopic heart transplantation