Giant Kawasaki coronary artery aneurysms and acute myocardial infarction: multimodal imaging.

Resection of Giant Coronary Artery Aneurysms in a Takayasu's Arteritis Patient

Patient: Male, 64-year-oldFinal Diagnosis: Huge coronary aneurysmSymptoms: Chest discomfort • dyspneaMedication: Losar 25 mg twice daily • Amlodipine 5 mg twice daily • Aspirin 80 mg daily • Atorovastatin 20 mg daily • Pantaprazole 20 mg dailyClinical Procedure: Coronary artery bypass graft surgerySpecialty: Cardiac Surgery • CardiologyObjective:Rare diseaseBackground:Giant coronary artery aneurysm (GCAA) is a rare disease, with an incidence of 0.02% in the general population. GCAA is defined as when the diameter of the coronary artery is more than 4 times the adjacent part or more than 8 mm. There are several causes of GCAA, with atherosclerosis being the most common. Patients with giant coronary artery aneurysms can be asymptomatic or develop chest pain, dyspnea, and palpitations. Complications of GCCA include myocardial infarction, thrombosis, and sudden death, so early treatment is necessary to prevent mortality. There is no standard surgical approach for a giant coronary artery aneurysm.Case Report:A 64-year-old man with hypertension, opium addiction, morbid obesity (body weight 151 kg and BMI 46), and benign prostate hyperplasia presented with a giant coronary aneurysm in coronary angiography. The patient underwent cardiac surgery, and a 42-mm coronary aneurysm was detected. The aneurysm had many orifices that opened to the left main coronary artery, left circumflex artery, LAD, the diagonal branch of the LAD, and the septal branch of the LAD. Aneurysmectomy and coronary artery bypass graft were successfully performed.Conclusions:Giant coronary artery aneurysms are rare. Patients with giant coronary artery aneurysms may experience sudden death due to myocardial infarction and other cardiovascular complications due to ischemia. Because it is rare, there is no standard surgical approach for a giant coronary artery aneurysm. Further studies need to focus on standardized surgical management of patients with giant coronary artery aneurysms.

Giant Aneurysm of the Left Atrial Branch of the Left Circumflex Artery With Fistula

Bilateral congenital coronary artery fistulae complicated with a giant coronary artery aneurysm is a very rare condition. A coronary artery aneurysm is a coronary artery dilatation that exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. The complications associated with a coronary artery aneurysm include thrombosis, embolization, rupture, vasospasm, congestive heart failure and infectious endocarditis. We report on a 63-year-old woman presenting with severe heart failure related to bilateral coronary artery fistulae. A giant coronary aneurysm was noted in the right coronary artery, and a tortuous coronary artery fistula was noted in the left coronary artery. Symptoms were relieved after surgical intervention for bilateral coronary artery fistulae.

Kawasaki disease or mucocutaneous lymph node syndrome is an acute, febrile vasculitis of unknown etiology affecting mainly infants and children under five years of age.Coronary artery involvement, which occurs in approximately 20% of such patients, may be the most important feature of this syndrome.In this paper, we report a successful coronary artery bypass graft in a nine-year-old boy with a giant coronary artery aneurysm and diffuse coronary artery disease.

Giant coronary aneurysms, from diagnosis to treatment: A literature review

A coronary artery aneurysm is uncommon and frequently asymptomatic. This report presents a surgical case of a giant coronary artery aneurysm complicated by acute myocardial infarction. A 26-year-old man with sudden chest pain was referred to our hospital. Myocardial infarction was suspected, and emergency coronary angiography was performed. A giant coronary aneurysm was found in the mid-portion of the right coronary artery. The aneurysm, which was thrombosis-occluded, was successfully resected, and the right coronary artery was anastomosed in an end-to-end fashion. Although the strategy for treating a coronary artery aneurysm without myocardial ischemia remains controversial, surgical intervention should be considered in cases with a giant coronary artery aneurysm, even if asymptomatic, provided the surgical risk is low.

BACKGROUNDGiant coronary artery aneurysms (CAA), entailing thrombosis, myocardial infarction, and sudden death, are the most severe and life-threatening complications of Kawasaki disease (KD). Giant aneurysms rarely regress and can later transform into stenoses. Data on dynamic follow-up are scarce in the literature.AIMTo evaluate clinical features and long-term outcomes of giant CAA in children with KD.METHODSA single-center retrospective study included data from patients with KD and giant CAA in the Irkutsk region (2012-2023). CAA criteria according to the American Heart Association guidelines of 2017 were used: (1) Dilated coronary artery with diameter Z-score > 2 standard deviations (SD) but < 2.5 SD; (2) Small CAA with Z-score > 2.5 SD but < 5 SD; (3) Medium CAA with Z-score > 5 SD but < 10 SD; and (4) Giant CAA with Z-score > 10 SD or ≥ 8 mm.RESULTSThe mean age of children with coronary dilatation/aneurysms was 2.5 years, and the male-to-female ratio was 3:1. Patients with giant/medium CAA had symptoms of cerebral dysfunction more often compared with children with moderate (Z-score < 5 SD but > 2.0 SD) coronary dilatation (62.0% vs 21.0%, P = 0.019). Major cardiovascular events (myocardial infarction, coronary artery bypass grafting, acute coronary syndrome, ischemic cardiomyopathy, left ventricular aneurysm, and giant extracardiac aneurysm) occurred in 55.5% of patients who had giant CAA. At follow-up the complete regression of giant/medium CAA was observed in 58.0% and partial regression in 42.0% after a mean of 2.3 and 5.5 years, respectively. All thrombi detected by echocardiography, CT, and angiography in giant/medium CAA disappeared between 1 year and 5 years (mean: 15 months). All patients survived.CONCLUSIONRisk factors for giant CAA were male sex, early age, and cerebral dysfunction. Complete regression of giant coronary aneurysms occurred in 58.0% of patients after follow-up of 2.3 years.

Coronary artery fistula, defined as communication between a coronary artery and a great vessel or a cardiac chamber, is a relatively rare anomaly with an estimated incidence of 0.002% in the general population. It could be combined with a giant coronary artery aneurysm, with an incidence of 5.9% of the total incidence rate of CAF in the general population. The pathogenesis of these two combined anomalies is not clear, and we aimed to detect whether genetic abnormalities underlie the pathogenesis of these rarely combined anomalies. A 6-year-old patient with a diagnosis of the right coronary artery to right ventricle fistula combined with a giant right coronary artery aneurysm and patent ductus arteriosus underwent a surgical repair at our center. The diagnosis was confirmed by echocardiography, CT, and surgery. DNA was extracted from the peripheral venous blood samples of the patient and his mother after informed consent was obtained. Hematoxylin and Eosin (HE) and Alizarin red staining were performed on the excised coronary artery aneurysm. Exome sequencing and in silico analyses were performed to detect detrimental genetic variants. No obvious abnormalities were found in the excised coronary artery aneurysm. A heterozygous truncated variant (NM_144573: c.G298T; p.G100X) in the NEXN gene and a missense variant (NM_001171: c.G1312A; p.V438M) in the ABCC6 gene were carried by the patient but not by his mother. The NEXN-truncated variant, NEXN-G100X, is associated with the development of coronary arteries and congenital coronary artery anomalies.

To investigate the clinical features and surgical management of giant coronary artery aneurysm during end-stage Kawasaki disease. From May 2006 to October 2007, 5 patients, 2 to 57 years old, presented with giant coronary artery aneurysm and underwent surgical correction. The coronary aneurysm diameters were 1.5 to 2.5 cm. The coronary aneurysm lesion sites included the right main coronary artery in 1 case, the left main coronary artery in 2 cases, and both the left and right coronary arteries in 2 cases. Preoperative electrocardiogram revealed altered S-T segments in 5 cases and reduced ejection fraction values in 3 cases, resulting in 1 emergency admission for congestive heart failure. Surgical treatments included thromboendarterectomy, thrombectomy, and aneurysmal reconstruction under the orthophoria of extracorporeal circulation. There were no operative deaths. All patients recovered and received dopamine 2 to 4 microg/min per kg and nitroglycerine 0.3 to 0.5 microg/min per kg. Time spent by patients in intensive care was uneventful. Following surgery, 4 patients showed ischemic improvement of the S-T segment on electrocardiograms, and 4 patients presented with increased ejection fraction, according to cardiac ultrasound inspection. The improvement of ejection fraction value was not significant in only 1 case. Surgery is necessary for stage-3 Kawasaki disease patients that have giant coronary artery aneurysm complications. Surgical treatment includes thromboendarterectomy, thrombus clearing, aneurysmal reconstruction, and coronary artery bypass grafting, followed by postoperative anticoagulation and immunotherapy. Myocardial ischemia and cardiac function can be greatly improved through surgery.

A 20-year-old woman visited our cardiology clinics for regular follow-up of Kawasaki disease. She was diagnosed with a giant coronary aneurysm at age 4. Her last coronary angiography was obtained 6 years before her current admission. To investigate the status of her coronary aneurysm, contrast-enhanced coronary computed tomographic (CT) angiography was performed with a 16-slice CT scanner. The CT was performed with retrospective …

Introduction Kawasaki Disease (KD) is the commonest childhood acquired heart disease in developed countries, predominantly affecting children younger than 5 years’ of age. These patients are at high risks of developing coronary arterial aneurysms (CAA) and CAA with absolute internal luminal diameters measuring ≥8mm or Z-score ≥10 are classified as giant coronary aneurysms (GCA). Case Report A 19-year-old girl with previous history of Kawasaki disease was diagnosed with giant coronary aneurysms on echocardiograms. Her subsequent CT coronary angiography showed large aneurysms in the right coronary artery (29mm x 25mm) and left anterior descending artery (10mm x 10mm) with signs of calcification. However, surprisingly, despite the evidence of large coronary aneurysms, she was completely asymptomatic and was physically active, participating in competitive sports. Her cardiac MRI scan 17 years after KD onset showed right coronary perfusion deficit in the distal right coronary territory but with no evidence of myocardial infarction. A repeated cardiac CT was performed and showed delayed filling of the distal right coronary artery. However, it was uncertain at this point if the aneurysm was causing true ischaemia or simply delayed perfusion. An ECG stress test was subsequently performed for further investigation which showed no significant abnormality. After having a detailed discussion in the MDT and with colleagues from San Diego, USA, a conservative approach was decided to be in the patient’s best interest. She has been advised to avoid competitive or strenuous exercise due to the associated risks. She is fit-and-well, and is currently on Warfarin variable dose and Aspirin 75mg OD, with annual cardiac MRI surveillance. Discussion 20% of KD patients develop CAA and approximately 5% of KD patients have evidence of GCA. Unlike small and medium CAA, GCA regress in a much slower and more constant rate, and they never achieve complete resolution. A Japanese retrospective study showed the 10-year coronary event-free survival rates in small, medium and giant CAA as 100%, 96% and 61% respectively (p&amp;lt;.001). Patients with GCA are at significantly increased risks of coronary complications and major cardiac events (48%). Despite maximal medical treatment, patients with GCA have high risks of aneurysm rupture which is associated with high mortality rates. These patients are also at lifelong risks of atherosclerosis and stenosis which may lead to myocardial ischaemia and even death. Therefore, it is absolutely essential to control for cardiovascular risk factors and adhere to strict treatment regime. These patients also require lifelong, uninterrupted cardiology follow-up in a specialist KD clinic. Catheter and surgical interventions may be indicated in some patients. There have been recent attempts in combining CABG with downsizing reconstruction for GCA in an attempt to decrease GCA diameter and improve the coronary flow rate to prevent thrombosis which has shown quite promising results. However, the decisions whether to undergo a surgical intervention should be tailored to each individual, taking into consideration all aspects of a patient, including their disease status and social life. Conclusion With an increasing prevalence of KD in UK, it is essential to always consider the diagnosis of KD in a febrile child with raised inflammatory markers, especially in patients presenting with prolonged fever (longer than 4-5 days) as a delay in commencing treatment poses a significantly increased risk of developing coronary complications which are associated with high morbidity and mortality rates.

We report the case of a 66-year-old man with a left anterior descending (LAD) coronary artery aneurysm. Cigarette smoking and hepatitis C virus infection were in his clinical history. Coronary angiography performed in 2002 showed a LAD aneurysm, a 50% stenosis of the right coronary artery, and a 30% stenosis of the left main artery (Figure 1, a through c). The ECG in 2002 was normal (Figure 2b i ). In 2002, the patient underwent successful Jomed polytetrafluoroethylene (PTFE)-coated stenting (3.0×20 mm) to cover the aneurysm (Figure 1d). After stenting, the patient was discharged on ticlopidine 250 mg/d for 1 year, aspirin 100 mg/d, metoprolol 25 mg/d, and transdermal nitrates. Figure 1. LAD …

Successful Revascularization of Multiple Coronary Artery Aneurysms Using a Combination of Surgical Strategies

We describe a rare case of coronary artery aneurysms due to Kawasaki disease in an elderly patient. Our case presents multiple giant coronary artery aneurysms affecting the left coronary system which is less common compared with right coronary aneurysms. Giant coronary artery aneurysms are uncommon; even more rare is their association with ischemic symptoms, and treatment can be challenging. We describe a case of symptomatic multiple coronary artery aneurysms with symptom relief after coronary artery bypass grafting in an elderly patient.