SUCCESSFUL MULTI-VESSEL CORONARY ARTERY BYPASS GRAFT IN A PATIENT WITH KAWASAKI DISEASE AND BILATERAL GIANT CORONARY ARTERY ANEURYSMS WITH INTRACORONARY THROMBUS BURDEN CAUSING A MYOCARDIAL INFARCTION: A CASE REPORT

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Kawasaki Disease (KD) is a small to medium sized vessel vasculitis which usually occurs in children aged from 6 months to 5 years old [1]. A complication of KD is coronary artery aneurysms (CAA) which can pose a risk of thrombosis and progressive stenosis with the development of ischemic heart disease, myocardial infarction, and sudden cardiac death [2,3]. The following case report presents a young male with KD and giant CAA undergoing multi-vessel coronary artery bypass graft (CABG) surgery following a myocardial infarction. Consent for presentation was obtained from patient’s parents. CASE PRESENTATION: A 17 yo Caucasian male with known KD presented to the ED with new onset chest pain. Initial EKG showed T-wave inversions in aVL, V4-V6 leads. Laboratory analysis included a serum troponin of 54 ng/L and INR of 1.6. Initial therapy included aspirin and a heparin infusion. Echocardiogram demonstrated a dilated aortic root. Repeat EKG consistent with a lateral STEMI. Emergent coronary angiography remarkable for possible dissection of left main coronary artery vs intracoronary thrombus. Coronary CTA obtained which confirmed extensive thrombus burden in LM and RCA as well as 100% occlusion of LAD and distal portion of RCA. Admitted to the CVICU and started on infusions of altepase, heparin, and abiciximab. Two-vessel CABG surgery performed on hospital day #6 with internal mammary artery grafts to RCA and LAD. Discharged on post-op day #4/hospital day #10 on aspirin, statin, beta-blocker, and apixaban. DISCUSSION: KD associated giant coronary artery aneurysms (GCAA) are a serious complication associated with acute myocardial infarction. GCAA are defined as an internal diameter of >8mm. With GCAA >8mm, regression is less likely and often leads to myocardial ischemia or infarction with an increased mortality rate [2]. In a study of CABG vs PCI in KD patients, CABG patients were more likely to have complete revascularization and required less re-intervention then PCI patients [3]. Arterial graft usage (internal thoracic artery) in CABG showed improved graft patency, long-term life expectancy, and growth potential compared to saphenous vein harvesting [3]. CONCLUSIONS: Seventeen-year-old male with Kawasaki Disease and giant coronary artery aneurysms presents with a lateral STEMI secondary to intracoronary thrombus burden. Coronary angiography and Coronary CTA demonstrated enlargement of both known aneurysms and intracoronary thrombus inducing total occlusion of LAD and distal RCA requiring multi-vessel CABG surgery. Reference #1: 1: CME “Rare Refractory Kawasaki Dz in an Adolescent Boy with Cardiac and Diffuse Coronary artery involvement” Reference #2: 2: Lin MT, Sun LC, Wu ET, Wang JK, Lue HC, Wu MH (2015) Acute and late coronary outcomes in 1073 patients with Kawasaki disease with and without intravenous-immunoglobin therapy. Arch Dis Child 100(6):542-547 Reference #3: 3: Dionne A, Bakloul M, Manlhiot C, et al. Coronary artery bypass grafting and percutaneous coronary intervention after Kawasaki disease: the Pediatric Canadian series. Pediatric cardiology. 2017;38(1):36-43. DISCLOSURES: No relevant relationships by Matthew Ellison, source=Web Response No relevant relationships by Kevin McKillion, source=Web Response No relevant relationships by Patrick McKillion, source=Web Response