Giant Kawasaki coronary artery aneurysms and acute myocardial infarction: multimodal imaging
Year: 2025
Type: article
Study design: Case Report
Abstract: A 20-year-old man was admitted for a 5-day acute left chest pain. Laboratory test showed an elevated urinary natriuretic peptide of 2527 pg/ml and troponin-T of 5059.0 ng/l. Coronary computed tomography angiography (CCTA) (Fig. 1a and b) on admission demonstrated three giant aneurysms with calcification in the left main (2.8 cm), left anterior descending (2.4 cm), and right (3.3 cm) coronary arteries, the two latter of which and adjacent proximal coronary arteries were occluded by thrombosis, and only faint contrast enhancement in the distal coronary arteries. Cardiovascular MRI (CMR) (Fig. 1c and d) revealed diffuse subendocardial and transmural late gadolinium enhancement (LGE) in both ventricular walls with poor left ventricular wall contraction in segments with LGE (Videos S1 and S2) and left ventricular ejection fraction (LVEF) of 24.5%. Resting myocardial perfusion imaging showed extensive myocardial ischemia in the inferior, high lateral, and septal left ventricular wall (Fig. 1e). Acute myocardial infarction by thrombosis in giant Kawasaki coronary aneurysms was diagnosed. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_qj0tnb5j"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_86d9ctbg"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1: Multimodality images of giant Kawasaki coronary artery aneurysms and myocardial infarction in a 20-year-old man. (a) Coronary CT angiography shows giant aneurysms in the left main, left anterior descending, and right coronary arteries, the two latter of which were nearly occluded by thrombosis. (b) Volume-rendered view of whole coronary CT angiography showed occlusion of proximal coronary arteries adjacent to the aneurysms and faint contrast enhancement in the distal coronary arteries. (c and d) Cardiovascular magnetic resonance images show diffuse subendocardial and transmural late gadolinium enhancement in both ventricular walls. (e) Resting myocardial perfusion image shows extensive myocardial ischemia in the inferior, high lateral, and septal LV wall. CT, computed tomography; LV, left ventricular.Both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were considered technically challenging and high-risk. PCI was limited by the risk of stent malapposition and thrombotic occlusion in lesions with giant aneurysms. Although CABG is the standard of care in complex multivessel aneurysmal disease, which can improve patient outcomes [1], it was not conducted in this patient, considering perioperative heart failure for extensive transmural LGE and severe left ventricular dysfunction, as well as the technical challenge of surgery posed by occlusion of adjacent coronary arteries and poor visualization of distal coronary arteries. After multidisciplinary discussion, and considering the patient’s hemodynamic stability, alternative medical therapy with long-term anticoagulation and antiplatelet agents (clopidogrel bisulfate 75 mg/day and aspirin 100 mg/day, administrated orally) was selected, consistent with current consensus that antithrombotic therapy is central when revascularization cannot be safely performed [1]. Follow-up CCTA 3 months and CMR 1 year after discharge showed essentially unchanged appearance of the aneurysms and distal coronary artery, as well as LGE and poor left ventricular contraction in the myocardium. Previous studies have reported that patients with LVEF less than 30% have significantly reduced long-term survival after CABG, with a 5-year survival rate of approximately 72% [2]. In the present case, despite the markedly reduced LVEF of 24.5%, the patient remained clinically stable during an 8-year follow-up – he experienced no recurrent ischemic events, and the antithrombotic strategy did not undergo adjustments or discontinuations during follow-up. This outcome not only confirmed the efficacy of the applied therapy but also highlighted the potential role of optimized medical therapy in carefully selected cases with left ventricular dysfunction. In addition, further advanced imaging was not performed in this patient because he remained clinically stable without recurrent events. Coronary artery aneurysms in Kawasaki disease are associated with high-risk cardiovascular events; myocardial infarction prevalence increases with aneurysm size [1]. Multimodality imaging plays an essential role in diagnosis, comprehensive evaluation, and surveillance of patient condition. Acknowledgements This work was supported by grants from the 1-3-5 project for disciplines of excellence of West China Hospital, Sichuan University (ZYGD23019) and Sichuan Provincial Science and Technology Plan Project (2024YFFK0259). The materials are available from the corresponding author upon reasonable request. Conflicts of interest There are no conflicts of interest.
Source: Coronary Artery Disease
Authors: Wei-Feng Yan, Xue-Ming Li, Zhi-Gang Yang
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4416865496