Page 25 - Journal of Structural Heart Disease Volume 2, Issue 5

Case Report
226
and hypokinesia of the posterior wall.
Subsequent coronary angiography showed a left
coronary artery with formation of a moderate sized aneurysm, with preserved patency and no intracoro- nary thrombus formation. The RCA however was completely occluded (Figure 1A and B). We immedi- ately attempted to revascularize the presumably thrombosed RCA. A 0.0018’’ coronary guide wire (SV-8, Cordis) was repeatedly advanced into the os- tium of the RCA and could be advanced several milli- meters. Thereafter, intracoronary thrombolysis was started with tissue-plasminogen activator (rT-PA) in- jections at aliquot doses of 1–2 mg. This led to partial thrombolysis and improved visualization of the RCA, showing a large aneurysm lled with thrombotic ma- terial (Figure 2A and B). Repetitive direct intracoro- nary thrombolysis in combination with mechanical thrombus fragmentation using the guide wire and direct thrombus aspiration over the 6 F coronary guide catheter nally resulted in complete visualiza- tion of the RCA (Figure 2C), revealing two large aneu- rysms in combination with two severe stenoses with a diameter of less than 1 mm between them. The ste- noses were dilated with a 3-mm coronary balloon (Savy, Cordis) at a maximum pressure of 6 atmo- spheres to improve coronary perfusion (Figure 2D and E). After a total dose of 20 mg intracoronary rT-PA, complete reperfusion of the RCA was achieved (Fig- ure 2F). After complete revascularization, the exact anatomy of the RCA became evident, showing two giant aneurysms combined with severe stenosis (Fig- ure 3). A coronary stent was not used due to the anat- omy of the RCA, to avoid both malpositioning of the stent in the aneurysm and the risk of acute secondary thrombotic occlusion. The patient was transferred to the PCICU, and a combination therapy of clopidogrel (75 mg), acetylsalicylic acid (100 mg), and hepariniza- tion was administered for the subsequent three days. Control echocardiography on days 2 and 3 con rmed full recovery of the ventricular function. Troponin I levels decreased to normal (Figure 4). A scheduled re- catheterization 3 days later showed complete and full restoration of coronary perfusion. The ECG normal- ized, showing normal function of the left ventricle without dyskinetic areas or apparent scarring. The pa- tient recovered completely and was discharged with a combination therapy of acetylsalicylic acid and war-
farin (target INR between 2.0 and 3.0). Planned con- trol catheter evaluations after 6 and 12 months re- vealed excellent cardiac function and a patent RCA without new thrombus formation.
Despite an initial lack of evidence, the child’s past medical history revealed a possible diagnosis of un- treated atypical KD 6 months previously. He pre- sented to another hospital with acute febrile illness for about 2 weeks, but with no signs of conjunctivitis, rash, mucosal changes, or lymphadenopathy. After 2 weeks, the fever disappeared and desquamation of the palms was visible. Echocardiography performed on days 4 and 10 of the illness was unremarkable. Fol- low-up echocardiography was advised, but the pa- tient did not present to a pediatric cardiologist for follow-up examination.
Discussion
KD is one of the most important causes of acute cor- onary syndrome in young adults. About 5% of all pa- tients with KD develop ischemic heart disease during long-term follow up, which is often associated with calci ed stenosis [4, 5]. Catheter intervention is now established as a rst-line therapeutic strategy for adult patients with coronary artery disease, and has pro- vided satisfactory therapeutic results [6]. However, in adult as well as pediatric patients with KD, limited experience with catheter interventions has been reported [4, 7, 8]. Options for coronary revasculariza- tion in KD generally consist of intravenous coronary thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting [9, 10, 11, 12]. The guidelines for catheter interventions in KD, published by the research committee of the Japanese Ministry of Health, Labor, and Welfare, indicate that patients with acute myocardial infarction after KD can be candidates for percutaneous transluminal coronary revasculariza- tion and intravenous thrombolysis, patients with stenotic lesions with mild calci cation can be candi- dates for percutaneous transluminal coronary balloon angioplasty (PCBA), and patients with severe calci ca- tions can be candidates for rotational ablation [13].
Primary percutaneous coronary interventions in children presenting with clinical symptoms of acute myocardial infarction due to the sequelae of KD have been extremely limited and restricted primarily to
Journal of Structural Heart Disease, October 2016
Volume 2, Issue 5:224-230