Progressive Left Coronary Stenosis After Rotablator Ablation Appreciated by Doppler Echocardiography

Abstract

We describe a patient with a history of Kawasaki disease who showed coronary jet flow in the giant aneurysm on color-Doppler echocardiography caused by progressive coronary stenosis. A 6-year-old boy who had bilateral giant coronary aneurysms (14.9 mm in diameter) of the left main trunk (Fig. 1a) as sequelae of Kawasaki disease presented to us with anginal chest pain. Two years ago he had undergone coronary artery bypass graft surgery using the bilateral internal mammary artery grafted to the left anterior descending and left circumflex artery. Coronary angiography this time showed obstruction of both right and left internal mammary arteries. A color-Doppler echocardiography showed an aliased jet originating from the coronary ostium and flowing into the left giant coronary aneurysm with an early peak diastolic flow of 1.6 m/s (normal: 0.18– 0.3) with acute deceleration, being much faster than peak systolic flow velocity of 1.0 m/s (Fig. 1b). Because it was difficult to repeat the bypass graft surgery, he underwent successful rotablator ablation of the left coronary stenosis using 1.5-mm burr and the left coronary stenosis was significantly alleviated with a decreased peak diastolic flow velocity of 1.0 m/s (Fig. 1c) and temporary resolution of anginal chest pain. However, 2 months later, he complained of refractory chest pain again, with accelerated diastolic left coronary flow velocity of 2.0 m/s and underwent another attempt at rotablator ablation, but, unfortunately, he fell into shock during the procedure and could not be saved with multiple resuscitations. This case illustrates that color-Doppler echocardiography is a useful tool for evaluating coronary artery stenosis with a giant coronary aneurysm caused by Kawasaki disease and also emphasizes the difficulty of treating these small children with coronary stenosis [1, 2].