Induced apnea for better CT visualization of coronary arteries in children under 1 year. And is heart rate so essential?

The authors propose a two‐dimensional echocardiographic approach to demonstrate the origin and proximal course of the coronary arteries in children, which could be called “suprasternal right anterior oblique cut”. The important feature disclosed by this new view, but not by the classic parasternal short‐axis cut, is the spatial relationship between the origin of the coronary arteries, the aortic root, and the ascending aorta. The knowledge of this anatomical feature may be of surgical significance in the setting of congenital heart diseases, such as tetralogy and transposition or acquired coronary diseases, such as Kawasaki's syndrome. The suprasternal right anterior oblique cut was obtained by rotating the transducer counterclockwise, with slight anterior tilting, from the classic long‐axis view of the aorta, for imaging the left coronary artery. The left coronary artery arises as a main trunk from the upper portion of the left coronary sinus, passes behind the pulmonary trunk and beneath the left atrial appendage for a few millimeters up to the point of bifurcation. Because of the orientation of the ultrasound beam, the left coronary is shown between the right pulmonary artery and the left atrial appendage in this cut. To assess the right coronary artery, the transducer was slightly deviated to the right and further rotated counterclockwise, while very carefully tilted anteriorly. Fifty consecutive children (29 males, 21 females), with a mean age of 5.4 ± 4.1 years, were evaluated from May to July 1992, in order to demonstrate the feasibility of the proposed approach. The left coronary artery was disclosed in 100% of cases, and the right in 76%. The 12 patients in which the right coronary artery was not visualized were significantly older than the group in which both coronary arteries were demonstrated (P < 0.001). It was concluded that the suprasternal right anterior oblique two‐dimensional echocardiographic cut for demonstration of the coronary arteries in children is easy to perform, reproducible, and allows the assessment of anatomical features not disclosed by the classic approach.

Objective: To analyze the clinical characteristics, diagnosis and treatment of anomalous aortic origin of a coronary artery (AAOCA) in children. Methods: There were 17 children diagnosed with AAOCA from January 2013 to January 2022 in Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine.Their clinical manifestations, laboratory and imaging data, treatment and prognosis were retrospectively analyzed. Results: These 17 children included 14 males and 3 females, with the age of (8.7±3.5) years. There were 4 anomalous left coronary artery (ALCA) and 13 anomalous right coronary artery (ARCA). Seven children presented with chest pain or chest pain after exercise, three patients presented with cardiac syncope, one complained chest tightness and weakness, and the other six patients had no specific symptoms. Cardiac syncope and chest tightness occurred in patients with ALCA. Fourteen children had the dangerous anatomical basis of myocardial ischemia caused by coronary artery compression or stenosis on imaging. Seven children had coronary artery repair, of whom two were ALCA and five were ARCA. One patient had received heart transplantation because of heart failure. The incidence of adverse cardiovascular events and poor prognosis in ALCA group was higher than that in ARCA group (4/4 vs. 0/13, P<0.05). They were followed up in the outpatient department regularly for 6 (6, 12) months; except for the one who lost visit, the rest of the patients had a good prognosis. Conclusions: Cardiogenic syncope or cardiac insufficiency usually occurs in ALCA, and adverse cardiovascular events and poor prognosis are more common in ALCA than in ARCA. Early surgical treatment should be considered for children with ALCA and ARCA accompanied by myocardial ischemia.

The extent of narrowing of the coronary arteries was measured in a series of 106 children who died accidentally. The outer radius of left main stem coronary artery increases from 1.06 mm at the age of 1 to 1.67 mm at 15. The left anterior descending branch increased with age from 0.70 to 1.35 mm and the inner radius from 0.55 to 1.10 mm. The mean thickness of the media and intima also increased with age; the correlation between thickness and weight was less pronounced. The coronary arteries thickened concomitantly with the size of the artery but that was due mainly to thickening of the intima. Substantial narrowing was found in the youngest age groups and the extent did not correlate with age but with the size of the vessel. The greatest narrowing was 57% of the arterial lumen. The measured dimensions will serve as normal values for the coronary arteries in Finnish children at autopsy.

Ostial atresia of the left main coronary artery (LMCA) in children without any primary disease is extremely rare. We present here a case of occlusion of the LMCA in a 9-year-old girl. Myocardial scintigraphy showed poor perfusion in both domains of the left anterior descending artery (LAD) and left circumflex artery (LCx). Coronary artery graphy (CAG) showed complete ostial atresia of the LMCA and retrograde perfusion from the thin collateral arteries into the LAD. We performed angioplasty using an autologous pericardium onlay patch. Her postoperative course was unremarkable. Postoperative CAG showed vanishing collateral arteries, confirming anterograde flow through the LAD and LCx, and myocardial scintigraphy showed improvement in perfusion.

We conducted a systematic review and meta-analysis of the literature to assess the outcomes of surgery for the anomalous aortic origin of a coronary artery in children and young adults (<30 years). Thirteen publications were selected, including a total of 384 patients. Unroofing of the intramural segment was adopted in 92% (95% CI: 81%-98%) of cases, with pooled early and late mortality of 0% (95% CI: 0%-0.3%) and 0.1% (95% CI: 0%-1%), respectively. Reoperation for aortic regurgitation was anecdotal. Surgical management of anomalous aortic origin of coronary arteries can be achieved with excellent results in pediatric patients, but concerns remain about the durability of surgery.

The objective of this study was to assess factors affecting image quality of 320-row computed tomography angiography (CTA) of coronary arteries in children with congenital heart disease (CHD). We retrospectively reviewed 28 children up to 3 years of age with CHD who underwent prospective electrocardiography (ECG)-gated 320-row CTA with iterative reconstruction. We assessed image quality of proximal coronary artery segments using a five-point scale. Age, body weight, average heart rate, and heart rate variability were recorded and compared between two groups: patients with good diagnostic image quality in all four coronary artery segments and patients with at least one coronary artery segment with nondiagnostic image quality. Altogether, 96 of 112 segments (85.7 %) had diagnostic-quality images. Patients with nondiagnostic segments were significantly younger (10.0 ± 11.6 months) and had lower body weight (5.9 ± 2.9 kg) (each p < 0.05) than patients with diagnostic image quality of all four segments (20.6 ± 13.8 months and 8.4 ± 2.5 kg, respectively; each p < 0.05). Differences in heart rate and heart rate variability between the two imaging groups were not significant. Receiver operating characteristic analyses for predicting patients with nondiagnostic image quality revealed an optimal body weight cutoff of ≤5.6 kg and an optimal age cutoff of ≤12.5 months. Prospective ECG-gated 320-row CTA with iterative reconstruction provided feasible image quality of coronary arteries in children with CHD. Younger age and lower body weight were factors that led to poorer image quality of coronary arteries.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly. It is important to demonstrate the anomalous origin of the left coronary artery and its course before surgery. To explore the clinical diagnostic use of multidetector CT coronary angiography in detecting anomalous origin of the left coronary artery from the pulmonary artery in children. Nine children (2 boys, 7 girls) ages 2months to 9years with surgically confirmed anomalous origin of the left coronary artery from the pulmonary artery were studied. Clinical data, transthoracic echocardiography and CT coronary angiography images were retrospectively analyzed. Transthoracic echocardiography correctly diagnosed anomalous origin of the left coronary artery from the pulmonary artery in 7 of 9 patients (95% CI: 40-97%). CT coronary angiography revealed the anomalous origin of the left coronary artery in all children (95% CI: 66-100%). In a 4-year-old girl and a 9-year-old girl, CT coronary angiography showed dilation of the right coronary artery and collateral circulation between the right and the left coronary arteries. CT coronary angiography is a useful method to show the anomalous origin of the coronary artery in children with anomalous origin of the left coronary artery from the pulmonary artery, especially for patients in whom origin of the left coronary artery cannot be detected by transthoracic echocardiography.

1. Stary HC, Blankenhorn DH, Chandler AB, et al. A definition of the intima of human arteries and of its atherosclerosis-prone regions: a report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation 1992; 85:391–405. 2. Stary HC. Evolution and progression of atherosclerotic lesions in coronary arteries of children and young adults. Arteriosclerosis 1989;9(Suppl I): 19–32. 3. Zarins CK, Giddens DP, Bharadvaj BK, et al. Carotid bifurcation atherosclerosis: Quantitative correlation of plaque localization with flow velocity profiles and wall shear stress. Circ Res 1983;53:502–14. 4. Movat HZ, More RH, Haust MD. The diffuse intimal thickening of the human aorta with aging. Am J Pathol 1958: 34:1023–31. 5. Stary HC. Macrophages, macrophage foam cells, and eccentric intimal thickening in the coronary arteries of young children. Atherosclerosis 1987;64:91–108. 6. Glagov S, Zarins C, Giddens DP, et al. Hemodynamics and atherosclerosis: insights and perspectives gained from studies of human arteries. Arch Pathol Lab Med 1988;112:1018–31. 7. Strong JP, McGill HC Jr. The pediatric aspects of atherosclerosis. J Atheroscler Res 1969;9:251–65. 8. Newman WP III, Freedman DS, Voors AW, et al. Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis: the Bogalusa Heart Study. N Engl J Med 1986;314:138–44. 9. Tell GS, Mittelmark MB, Vellar OD. Cholesterol, high density lipoprotein cholesterol and triglycerides during puberty: the Oslo Youth Study. Am J Epidemiol 1985;122:750–76. 10. Lauer RM, Burns TL, Clarke WR. Assessing children’s blood pressure: considerations of age and body size: the Muscatine Study. Pediatrics 1985;75:1081–90. 11. Stary HC, Chandler AB, Glagov S, et al. A definition of initial, fatty streak, and intermediate lesions of atherosclerosis. Arterioscler Thromb 1994;14:840–856. 12. Virmani R, Kolodgie FD, Burke AP, et al. Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol 2000;20:1262–75. 15. Wagner WD, Salisbury BG. Aortic total glycosaminoglycan and dermatan sulfate changes in atherosclerotic rhesus monkeys. Lab Invest 1978;39:322–8. 16. Nakashima Y, Fujii H, Sumiyoshi S, et al. Early human atherosclerosis: accumulation of lipid and proteoglycans in intimal thickenings followed by macrophage infiltration. Arterioscler Thromb Vasc Biol 2007;27:1159–65. 17. Kwon GP, Schroeder JL, Amar MJ, et al. Contribution of macromolecular structure to the retention of lowdensity lipoprotein at arterial branch points. Circulation 2008;117; 2919–27. 18. Corretti MC, Anderson TJ, Benjamin EJ, et al. Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the International Brachial Artery Reactivity Task Force. J Am Coll Cardiol 2002;39:257–65. 19. Sorensen KE, Celermajer DS, Georgakopoulos D, et al. Impairment of endothelium-dependent dilation is an early event in children with familial hypercholesterolemia and is related to the lipoprotein (a) level. J Clin Invest 1994;93:50–5. 20. de Jongh S, Lilien MR, Bakker HD, et al. Family history of cardiovascular events and endothelial dysfunction in children with familial hypercholesterolemia. Atherosclerosis 2002;163:193–7.

The Child Coronary Arterial Diameter Reference Study Group of the Japan Kawasaki Disease Society recommends ultrasound imaging as the standard method for measuring the diameter of the coronary artery in children. The patient is examined in a supine or right decubitus position by using a sector probe (≥ 5 MHz). The coronary arterial diameter measured at the minimum gain setting is the distance between the internal echo edge and the internal echo edge. The diameter is measured during the early diastolic phase at the end of the T wave. The left main coronary artery and the proximal right coronary artery are approached from the precordial short axis at the level of the aortic valve. The proximal and mid-right coronary arteries are observed on the atrioventricular groove, anterior to the tricuspid valve ring. The right coronary artery of the acute margin of the heart runs along the right side of the tricuspid valve ring. The distal right coronary artery is observed on the posterior atrioventricular groove, and the posterior descending branch of the right coronary artery is observed on the posterior interventricular groove. The right coronary artery is also well observed from the right sternal border in the right decubitus position. Proximal and mid-anterior descending arteries are observed on the anterior interventricular groove. The proximal left circumflex coronary artery is observed in the atrioventricular groove, anterior to the mitral valve ring.

Objective To analysis the difference between the application of high-frequency probe and the use of low-frequency probe in detecting the coronary arteries in children by using echocardiography, including the imaging quality, inner diameter of the coronary artery, and coronary artery dilation to facilitate clinical diagnosis. Methods From November 2014 to November 2015, 215 children who were diagnosed as Kawasaki disease, underwent echocardiography examination in Capital Institute of Pediatrics. Twelve cases did the examination of the computed tomography angiography and echocardiography using high-frequency probe (S12-3) and the low-frequency probe (S5-1). The imaging quality, coronary artery size and the number of coronary artery dilation were compared after the examination. Results The imaging obtained by the use of high-frequency probe showed stronger contrast, higher resolution than using the lower-frequency probe. The opening of left and right coronary artery and the proximal part were showed extremely clear and the imaging of intima was echo-homogeneous. While the imaging of the low-frequency probe for young children, especially for babies was discovered poorly, with blurred intima and ill-defined margin. The diameter of coronary artery in high-frequency probe imaging was not significant different with CT images (P>0.05), but the data obtained from the low-frequency probe [(2.95±1.36) mm, (2.24±1.27) mm, (1.89±2.63) mm, (2.35±2.89) mm] was different with CT [(2.67±0.42) mm, (2.03±0.64) mm, (1.56±0.48) mm, (2.07±0.47) mm] (P<0.05). The maximum number of coronary artery dilation got from CT, second was that from the use of low-frequency probe, and followed by the use of high-frequency probe. Conclusions The high-frequency probe was more suitable for detecting coronary artery disease in KD infants. The images were more distinctewith more reliable data, and the examination was non-invasive, safe, and convenient.It was more appropriate for the diagnosis ofacute phase Kawasaki disease and patient follow-up in clinic. Key words: High-frequency probe; Kawasaki disease; Coronary artery

Surgical angioplasty of the main coronary arteries in children

To compare the visualization and anatomy of coronary arteries in children (≤ 2 years) with congenital heart disease (CHD) on non-electrocardiogram (ECG)-gated and ECG-gated computed tomography angiography (CTA). In this retrospective study, approved by the Ethics Committee of our institute, evaluation of coronary arteries in CHD was performed in 40 children on non-ECG-gated CTA and in 42 children on ECG-gated CTA. The origin and course of the right coronary artery (RCA), left main coronary artery (LMCA), left anterior descending (LAD) artery, and left circumflex (LCX) artery were evaluated by 2 paediatric radiologists independently. ECG-gated CT scans yielded increased (additional) visualization of all the coronary arteries, when compared to non-ECG-gated CT scans. The RCA, LMCA, LAD artery, and LCX artery were visualized in 47.5%, 62.5%, 55%, and 32.5% of children, respectively, on non-ECG-gated studies, while they were visualized in 64.3%, 92.8%, 80.9%, and 62% children, respectively, on ECG-gated studies. The coronary artery anatomical variations were also supplementarily detected more in the ECG-gated group (23.8%) than in the non-ECG gated group (2.5%). ECG-gated CT cardiac angiography studies yield enhanced diagnostic outcomes for the evaluation of the coronary arteries in comparison to non-ECG-gated studies.

Expert consensus guidelines: Anomalous aortic origin of a coronary artery

Acta PaediatricaVolume 93, Issue s446 p. 5-5 Coronary arteries in children. Anatomy, flow and function. A Marcus Wallenberg symposium Erkki Pesonen, Erkki PesonenSearch for more papers by this authorLars Holmberg, Lars HolmbergSearch for more papers by this author Erkki Pesonen, Erkki PesonenSearch for more papers by this authorLars Holmberg, Lars HolmbergSearch for more papers by this author First published: 02 January 2007 https://doi.org/10.1111/j.1651-2227.2004.tb00232.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume93, Issues446November 2004Pages 5-5 RelatedInformation

Transthoracic Doppler echocardiographic measurement of flow velocity and flow velocity reserve in the great cardiac vein and in the left anterior descending coronary artery in children with left ventricular volume overload secondary to ventricular septal defect