A fatal case of ruptured giant coronary artery aneurysm

Fibromuscular dysplasia of the coronary arteries: An unusual case of sudden death and review of the literature

Fibromuscular dysplasia of the coronary is an uncommon coronary defect with a range of pathological alterations and unpredictable clinical description that can cause sudden death. We present an autopsy case of sudden cardiac death due to a rupture of a coronary artery aneurysm in a 59-year-old woman. Postmortem autopsy revealed two huge saccular aneurysms located at the right coronary artery, one of which was ruptured leading to a fatal hemopericardium. Histopathological examination revealed coronary artery fibromuscular dysplasia with fibromyxoid dissociation of the media causing saccular aneurysms. The involvement of coronary arteries in fibromuscular dysplasia with aneurysmal features has been rarely reported in the literature and is most likely an underdiagnosed finding. Due to the little number of published studies, the etiology is not fully understood and data on pathogenesis, risk factors, manifestation, disease course, and mortality are still unclear, which is a gap that needs to be filled in order to avoid under-diagnosis of the disease. Our case report aimed to discuss the mechanisms of sudden death attributed to coronary fibromuscular dysplasia.

Huge Coronary Aneurysm in a Morbidly Obese Man with Exertional Dyspnea and Chest Pain

Patient: Male, 64-year-old

Final Diagnosis: Huge coronary aneurysm

Symptoms: Chest discomfort • dyspnea

Medication: Losar 25 mg twice daily • Amlodipine 5 mg twice daily • Aspirin 80 mg daily • Atorovastatin 20 mg daily • Pantaprazole 20 mg daily

Clinical Procedure: Coronary artery bypass graft surgery

Specialty: Cardiac Surgery • Cardiology

Importance of blood pressure control in Kawasaki disease with expanded multiple giant coronary aneurysms with a 32 mm maximum diameter: a case report

BACKGROUND

Ruptured coronary artery aneurysm is rare, but the most serious complications of an acute phase of Kawasaki disease (KD) with giant coronary artery aneurysm (GCAA). Progressive or super GCAA, which rapidly dilates and continue to increase over a diameter of 10 mm, are more susceptible to rupture.

CASE SUMMARY

We report the case of a 6-year-old boy with KD who had multiple super GCAAs with a high risk of GCAA rupture. On admission to our hospital, he presented with fever, chest pain, and Stage II hypertension. Echocardiographic Z-scores adjusted for body surface area were used for measurements. The coronary artery diameter of segment 1 was 24.3 mm with a Z-score of 20.8; the diameter of segment 3 was 24.4 mm; the diameter of the left anterior descending branch was 32.6 mm with a Z-score of 20.1. The super GCAAs showed a tendency to expand compared to the latest echocardiography, and thrombus formation was observed in the super GCAA of segment 3. The patient was treated with anti-inflammatory therapy, antithrombotic therapy, and antihypertensive therapy with continuous arterial pressure monitoring with the goal of not exceeding the 5th percentile of the normal standard during the period when there was a risk of progressive coronary aneurysm expansion. He was discharged without any neurological complications.

DISCUSSION

We speculated that the patient's hypertension was the cause of an expanding coronary artery aneurysm. In conclusion, KD patients with super GCAA may benefit from aggressive blood pressure control with continuous arterial pressure monitoring.

Rare case of Kawasaki disease with cardiac tamponade and giant coronary artery aneurysms

Kawasaki disease is an acute systemic vascular disease, generally self-limited and typically affecting children <5 years old, which leads to coronary artery aneurysms in about 25% of untreated cases. Cardiovascular involvement is characterised by transient pancarditis, in acute phase, while coronary illness, ranging from mild dilation to giant CAAs occurs late, rarely before the 10th day since fever onset. Here, we describe a peculiar case of KD, which occurred in a 4-month-old infant and presented with exudate cardiac tamponade and early giant aneurism of both the proximal right coronary artery) and the left circumflex coronary artery, in acute phase of the disease.

Challenges and strategies in the management of coronary artery aneurysms

Coronary artery aneurysms (CAAs) are infrequent but not rare. Because of the lack of supportive data and a substantial knowledge gap in this field, clinicians are in a dilemma how to manage patients with coronary artery aneurysms. Most often, CAAs are discovered incidentally, while symptomatic patients present with diverse complications of unstable angina, myocardial infarction, arrhythmias, or sudden cardiac death. Therapeutical approaches consist of surgical procedure, percutaneous coronary intervention (PCI), and medical management. Because of the scarcity of randomized trials or large-scale data on symptomatic and asymptomatic patients with coronary artery aneurysms, the management of these patients poses considerable challenges for the cardiologists. This review summarizes the current literature, a proposed algorithm for the management of CAAs is highlighted in the text. In view of the majority of current proposal information based on small series of case reports or observational studies, an individualized therapeutic regimen should be on the basis of the location, expansion by time, morphology, complications, and etiologies of the coronary artery aneurysms, the clinical presentations, and the patient's characteristics.

Lymph-node-first Kawasaki disease and giant coronary artery aneurysm

A 8-year-old Irish ethnicity girl presented with 3 days of fever with right-sided neck swelling which was first thought as acute tonsillitis with right-sided lymphadenitis. She was started on intravenous antibiotics. At day 7 of illness, she was diagnosed to have Kawasaki disease with clinical and biochemical evidence. Echocardiogram at day 9 of illness and subsequently CT cardiac angiogram performed revealed giant aneurysm at the right coronary artery with non-obstructing thrombus seen. The patient then commenced on clopidogrel and continued with a regular dose of aspirin. Due to the evidence of thrombus with a giant coronary aneurysm, she was also put on long-term warfarin therapy with regular monitoring of her international normalised ratio to be kept at the range of 2.0-3.0.

Giant left anterior descending artery aneurysm resulting in sudden death

Coronary artery aneurysm is a rare congenital or vascular inflammation-based anomaly for which the clinical course and optimal timing of treatment remain unclear. Here, we report a case of sudden death caused by a giant coronary artery aneurysm of the left anterior descending artery that presented with chest pain. This case suggests that urgent interventional or surgical repair is needed when a large coronary aneurysm presents with acute ischemic symptoms.

Sudden death due to isolated segmentary coronary vasculitis

Coronary vasculitis is a group of conditions occurring either independently or associated with another diseases characterized by an inflammation of the blood vessel's wall and subsequent fibrinoid necrosis, occlusion, stenosis, or aneurismal dilatations. Coronary vasculitis leading to sudden cardiac death has rarely been described in the scientific literature.We present the case of an 18-year-old football player who collapsed when playing football. The patient remained in a deep coma (glasgow coma scale = 3) in the hospital for another 4 hours before dying. During hospitalization, he was diagnosed with acute anterolateral myocardial infarction with ST elevation. An autopsy was performed the next day, and on the coronary vessels were identified a dilatation with luminal extension, which, based on clinical and pathological criteria, was considered to be an isolated, coronary polyarteritis nodosa.

Two cases of super-giant coronary aneurysms after kawasaki disease

Acute giant coronary aneurysm after Kawasaki disease (KD) is a catastrophic complication that can be fatal and very difficult to manage. However, no fixed consensus has been reached for the management of super-giant coronary aneurysms in the acute setting. Here, we report the successful management of young children with super-giant coronary aneurysms after KD. Based on our experience, hemodynamic stabilization to prevent further coronary dilation or rupture and strict anticoagulation to avoid thrombus formation are mandatory in the management of this condition.

Cell distribution differences of matrix metalloproteinase-9 and tissue inhibitor of matrix metalloproteinase-1 in patients with Kawasaki disease

The interaction of matrix metalloproteinase (MMP)-9 and tissue inhibitor of matrix metalloproteinase-1 has been implicated in the formation of coronary aneurysms in Kawasaki disease. MMP-9 and tissue inhibitor of matrix metalloproteinase-1 were distributed predominantly in the granulocytes and platelets, respectively, in patients with Kawasaki disease. The plasma values of MMP-9 correlated positively with the circulating neutrophil count. Inhibiting the activity of granulocytes and maintaining the platelet activity might prevent coronary aneurysms.

Epidemiologic features of Kawasaki disease in Japan: results of the 2007-2008 nationwide survey

BACKGROUND

The most recent epidemiologic features of Kawasaki disease (KD) are unknown.

METHODS

The 20th nationwide survey of KD was conducted in 2009, and included patients treated for the disease in 2007 and 2008. Hospitals specializing in pediatrics, and hospitals with pediatric departments and 100 or more beds, were asked to report all patients with KD during the 2 survey years.

RESULTS

From a total of 1540 departments and hospitals, 23,337 patients (11 581 in 2007 and 11 756 in 2008) were reported: 13,523 boys and 9814 girls. The annual incidence rates were 215.3 and 218.6 per 100,000 children aged 0-4 years in 2007 and 2008, respectively. These were the highest annual KD incidence rates ever recorded in Japan. The monthly number of patients peaked during the winter months; smaller increases were noted in the summer months. The age-specific incidence rate showed a monomodal distribution with a peak at age 9-11 months. The prevalences of both cardiac lesions during the acute phase of the disease and cardiac sequelae were higher among infants and older age groups.

CONCLUSIONS

The incidence rate and number of patients with KD in Japan continue to increase.

Interleukin-18 gene 105A/C genetic polymorphism is associated with the susceptibility of Kawasaki disease

Interleukin-18 (IL-18)-656T/G, -607A/C, and -137C/G promoter polymorphisms had been reported associated with Kawasaki disease (KD). An IL-18 genetic A/C polymorphism at coding position 105 (rs549908) has been linked with asthma, rheumatoid, and systemic lupus erythematosus. We tested a hypothesis that the IL-18 105A/C genetic polymorphism confers KD susceptibility. Study participants were Taiwanese KD patients and a healthy control group. Our data indicated that the frequency of C allele was significantly higher in the patient group (13.9%) than in the control group (2.7%; P<0.0001, odds ratio [OR]=5.93; 95% confidence interval [CI]=2.57-13.73). Therefore, persons with the C allele may have higher risk of developing KD. In addition, compared with the haplotype frequencies between case and control groups, the KD patients with TACC haplotype appeared to be a significant "at-risk" haplotype compared with other haplotypes (OR: 4.62, 95% CI: 1.71-12.43; P=0.001). KD patient with the TAGA haplotype appeared to be a significant "protective" haplotype compared with other haplotypes (OR: 0.51, 95% CI:0.29-0.89; P=0.017). Our results suggest that 105A/C polymorphism and the haplotypes in IL-18 gene are associated with the risk of KD in Taiwanese population.

Epidemiologic features of Kawasaki disease in Japan: results from the nationwide survey in 2005-2006

BACKGROUND

The most recent epidemiologic features of Kawasaki disease are unknown.

METHODS

The 19th nationwide survey of the disease was conducted in 2007, targeting patients who were affected by this disease in 2005 and 2006. All pediatric departments in hospitals with 100 or more beds and pediatric hospitals were asked to report all Kawasaki disease patients during the 2 survey years.

RESULTS

From 1543 departments and hospitals, a total of 20475 patients (10041 in 2005 and 10434 in 2006) were reported. There were 11892 male patients and 8583 female patients. The average annual incidence rate was 184.6 per 100000 children aged 0-4 years. The number of patients and the incidence rate have increased significantly during the past 12 years. The age-specific incidence rate was distributed monomodally with a peak at 6-8 months of age. The prevalence of cardiac lesions in the acute phase of the disease and of cardiac sequelae were higher among infants and old patients.

CONCLUSION

The number of patients with Kawasaki disease and its incidence rate in Japan are continuously increasing.