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Kakimoto N, Suzuki H, Taruya A, Takeuchi T, Suenaga T, Tsuchihashi T, Suzuki T, Shibuta S, Ino Y, Tanaka A, Tokuhara D. Vasa vasorum enhancement on optical coherence tomography in Kawasaki disease. Pediatr Res 2024:10.1038/s41390-024-03431-w. [PMID: 39039326 DOI: 10.1038/s41390-024-03431-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/26/2024] [Accepted: 07/07/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Patients with Kawasaki disease (KD) prone to develop coronary artery aneurysm (CAA) with unknown etiology. We aimed to disclose the relationship between vasa vasorum (VV) and intimal thickening using optical coherence tomography (OCT) in KD. METHODS Forty-three coronary artery branches of 21 patients with KD were examined by OCT. The coronary arteries were classified into three groups: the CAA group (n = 9) in which CAAs remained since the acute phase, the regressed group (n = 16) in which CAAs were regressed, and the no CAA group (n = 18). The number and distribution of VV, and intimal thickening in coronary arteries were evaluated on OCT. RESULTS Intimal thickening was significantly more severe in the CAA and regressed groups than in the no CAA group (median: 481, 474, and 218 μm, p = 0.001 and p < 0.001, respectively). The number of VV in the regressed group was significantly higher than that in the CAA and no CAA groups. The numbers of adventitial VV and internal VV were positively correlated with the intimal thickness (R = 0.64, p < 0.001; R = 0.62, p < 0.001, respectively). In the no CAA group, no internal VV were observed. CONCLUSIONS VV enhances according to intimal thickening, suggesting that VV may have some link to the healing process, such as CAA regression and intimal thickening. IMPACT Kawasaki disease (KD) is a vasculitis syndrome developing coronary artery aneurysm, however its etiology still remains unclear. Coronary artery imaging using optical coherence tomography (OCT) can reveal coronary arterial wall pathology, however OCT studies are limited in patients with KD. Using OCT, we disclosed the closed relationship between vasa vasorum enhancement and regressed coronary arterial lesions. Vasa vasorum enhancement is involved in the pathomechanism of the convalescent phase of KD.
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Affiliation(s)
- Nobuyuki Kakimoto
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Hiroyuki Suzuki
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
- Department of Pediatrics, Wakayama Tsukushi Medical and Welfare Center, Iwade, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Tomohiro Suenaga
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | | | - Takayuki Suzuki
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | | | - Yasushi Ino
- Department of Cardiovascular Medicine, Kinan Hospital, Tanabe, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Daisuke Tokuhara
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan.
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Newburger JW, Esch J. Shining a Light: Ocular Coherence Tomography and the Pathology of Late Convalescent Kawasaki Disease. JACC. ADVANCES 2024; 3:100938. [PMID: 38938867 PMCID: PMC11198198 DOI: 10.1016/j.jacadv.2024.100938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jesse Esch
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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3
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Sagiv E, Newland DM, Slee A, Olson AK, Portman MA. Real-world experience with edoxaban for anticoagulation in children at risk for coronary artery thrombosis. Cardiol Young 2024; 34:870-875. [PMID: 37921220 DOI: 10.1017/s1047951123003761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
BACKGROUND Direct oral anticoagulants have the potential to improve care in children requiring chronic anticoagulation. Edoxaban has favourable pharmacokinetics that could benefit younger patients but data on long-term safety and efficacy for specific paediatric indications are lacking. STUDY AIMS We present a single-centre experience using edoxaban in children who require chronic anticoagulation for large coronary artery aneurysms secondary to Kawasaki disease. METHODS Weight-based dosing of once-daily oral edoxaban was offered as alternative to standard anticoagulation for patients aged 1-18 years. Chart review was performed for a median follow-up period of 49 months on edoxaban. Steady-state pharmacokinetics and pharmacodynamics of edoxaban were also explored. RESULTS Sixteen patients on chronic therapy with edoxaban were included. No major bleeding events were reported. Two patients experienced coronary artery thrombosis after 23 and 38 months on edoxaban, 7 and 11 years after diagnosed with Kawasaki disease, respectively. This predicts 70% event-free rate at 12 years from diagnosis. Area under the curve estimates over the dosing interval of 24 hours were similar to those reported in adults. CONCLUSIONS Edoxaban use is feasible and well-tolerated for long-term use in paediatric population. We suggest appropriate exposure using weight-based once-daily dosing strategy that may be comparable to standard-of-care anticoagulation in prevention of coronary artery thrombosis. Larger studies are needed to evaluate long-term safety and efficacy of edoxaban in this population.
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Affiliation(s)
- Eyal Sagiv
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - David M Newland
- Department of Pharmacy, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Aaron K Olson
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
| | - Michael A Portman
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
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Bassareo PP, O’Brien ST, Dunne E, Duignan S, Martino E, Martino F, Mcmahon CJ. Should We Be Screening for Ischaemic Heart Disease Earlier in Childhood? CHILDREN 2022; 9:children9070982. [PMID: 35883966 PMCID: PMC9320497 DOI: 10.3390/children9070982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
Ischaemic heart disease is the most common cause of death in males and the second in the female gender. Yet we often only focus on identification and treatment of this foremost cause of death in adulthood. The review asks the question what form of coronary disease do we encounter in childhood, what predisposing factors give rise to atherosclerosis and what strategies in childhood could we employ to detect and reduce atherosclerosis development in later life.
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Affiliation(s)
- Pier Paolo Bassareo
- Mater Misercordiae Hospital, Mater, D07 R2WY Dublin, Ireland
- Children’s Health Ireland at Crumlin, D12 N512 Dublin, Ireland; (S.T.O.); (E.D.); (S.D.); (C.J.M.)
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Stephen T. O’Brien
- Children’s Health Ireland at Crumlin, D12 N512 Dublin, Ireland; (S.T.O.); (E.D.); (S.D.); (C.J.M.)
| | - Esme Dunne
- Children’s Health Ireland at Crumlin, D12 N512 Dublin, Ireland; (S.T.O.); (E.D.); (S.D.); (C.J.M.)
| | - Sophie Duignan
- Children’s Health Ireland at Crumlin, D12 N512 Dublin, Ireland; (S.T.O.); (E.D.); (S.D.); (C.J.M.)
| | - Eliana Martino
- Department of Paediatrics, La Sapienza University, 00185 Roma, Italy; (E.M.); (F.M.)
| | - Francesco Martino
- Department of Paediatrics, La Sapienza University, 00185 Roma, Italy; (E.M.); (F.M.)
| | - Colin J. Mcmahon
- Children’s Health Ireland at Crumlin, D12 N512 Dublin, Ireland; (S.T.O.); (E.D.); (S.D.); (C.J.M.)
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
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Etanercept with IVIg for acute Kawasaki disease: a long-term follow-up on the EATAK trial. Cardiol Young 2022; 33:613-618. [PMID: 35545881 DOI: 10.1017/s1047951122001470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Etanercept as Adjunctive Treatment for Acute Kawasaki Disease, a phase-3 clinical trial, showed that etanercept reduced the prevalence of IVIg resistance in acute Kawasaki disease. In patients who presented with coronary artery involvement, it reduced the maximal size and short-term progression of coronary artery dilation. Following up with this patient group, we evaluated the potential long-term benefit of etanercept for coronary disease. METHODS Patients were followed for at least 1 year after the trial. The size of dilated arteries (z-score ≥ 2.5) was measured at each follow-up visit. The z-score and size change from baseline were evaluated at each visit and compared between patients who received etanercept versus placebo at the initial trial. RESULTS Forty patients who received etanercept (22) or placebo (18) in the Etanercept as Adjunctive Treatment for Acute Kawasaki Disease trial were included. All patients showed a persistent decrease in coronary artery size measurement: 23.3 versus 5.9% at the 6-month visit, 24 versus 13.1% at the 1-year visit, and 20.8 versus 19.3% at the ≥ 2-year visit for etanercept or placebo, respectively, with similar results for decrease in coronary artery z-scores. In a multivariate analysis, correcting for patients' growth, a greater size reduction for patients on the etanercept arm versus placebo was proved significant for the 6-month (p = 0.005) and the 1-year visits (p = 0.019) with a similar end outcome at the ≥ 2-year visit. DISCUSSION Primary adjunctive therapy with etanercept for children with acute Kawasaki disease does not change the end outcome of coronary artery disease but may promote earlier resolution of artery dilation.
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Deep Learning-Based Approach to Automatically Assess Coronary Distensibility Following Kawasaki Disease. Pediatr Cardiol 2022; 43:807-815. [PMID: 34854943 DOI: 10.1007/s00246-021-02790-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
Kawasaki disease is an acute vasculitis affecting children, which can lead to coronary artery (CA) aneurysms. Optical coherence tomography (OCT) has identified CA wall damage in KD patients, but it is unclear if these findings correlate with any distensibility changes in the CA and how these changes evolve over time. This paper seeks to establish the link between OCT findings and vessel distensibility with a novel deep learning coronary artery segmentation system and use the segmentation framework to automatically analyze the temporal evolution of coronary stiffness over many years. 27 KD patients underwent catheterization with coronary angiography of the left coronary artery (LCA), followed by OCT of proximal and distal segments of the LCA. Changes in the CA caliber over the cardiac cycle were measured automatically and compared against OCT findings suggestive of KD-related vascular damage. In addition, 34 KD patients with regressed or persistent CA aneurysms were followed with serial CA angiography over an average of 14.5 years. Distensibility changes were calculated using a deep learning coronary artery segmentation framework and evaluated longitudinally. Distensibility in the coronary arteries after KD negatively correlated with increasing severity of OCT findings of KD-related vessel damage. KD patients have a significant increase in CA wall stiffness at 1 year after diagnosis, which then plateaus subsequently, compared to controls. Also, patients with persistent CA aneurysms have a statistically significant increase in wall stiffness over time in comparison to those with regressed CA aneurysms. Distensibility changes in the CA of KD patients calculated using our automated deep learning approach correlates with the severity of OCT findings of KD-related CA damage. This decreased distensibility peaks at 1 year in KD patients when following longitudinally and is more severe in those with persistent CA aneurysms.
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Ishikawa T, Uchiyama H, Mogi S, Ohtani H. Case Report: Structural Changes in the Coronary Vessel Wall in a Patient With Incomplete Kawasaki Disease. Front Pediatr 2022; 10:845723. [PMID: 35311040 PMCID: PMC8927284 DOI: 10.3389/fped.2022.845723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Kawasaki disease (KD) is an acute systemic vasculitis of infants and young children that affects medium-sized vessels. Conventional cardiac imaging techniques, such as cardiac catheterization, are useful for characterizing the coronary arterial lesion (CAL) size and luminal diameter of the diseased coronary artery segment in patients with KD, but there are limitations to the visualization of the detailed vascular anatomy. Optical coherence tomography (OCT) is a high-resolution intracoronary arterial imaging modality that can distinguish the three layers of the coronary arterial wall. Several studies have reported coronary artery wall abnormalities in KD patients with coronary arterial aneurysm or regressed aneurysm. However, there have been no reports on changes in the coronary artery wall in cases of incomplete KD without CAL. CASE PRESENTATION We herein report an 11-year-old girl with a history of incomplete KD without coronary arterial aneurysms. She had been diagnosed with perimembranous ventricular septal defect (VSD) after birth and had experienced incomplete KD at 1 year old. During her hospitalization for KD, she did not receive intravenous immunoglobulin (IVIG), because she did not meet the Harada score or criteria for treatment in patients with incomplete KD established by the American Heart Association. No dilatation or coronary artery aneurysm were observed on transthoracic echocardiography in the acute or follow-up period. At 11 years old, she received cardiac catheterization and coronary angiography (CAG) for the evaluation of a VSD and follow-up of KD. CAG demonstrated no aneurysm, dilatation, or significant stenosis of the coronary arteries. We performed an OCT study, which revealed the presence of intimal thickening, disruption of the media, and neovascularization in the left anterior descending artery. CONCLUSION OCT demonstrates the structural changes of CA even in the patient with incomplete KD who have not been treated with IVIG.
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Affiliation(s)
- Takamichi Ishikawa
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroki Uchiyama
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoshi Mogi
- Division of Cardiology, Internal Medicine 3, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hayato Ohtani
- Division of Cardiology, Internal Medicine 3, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Donisan T, Mertens A, Luay S. Kawasaki Related Coronary Artery Disease Refractory to Angioplasty: The Role of Intravascular Shockwave Lithotripsy. Cureus 2021; 13:e19020. [PMID: 34853747 PMCID: PMC8608039 DOI: 10.7759/cureus.19020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/12/2022] Open
Abstract
Kawasaki disease is a systemic vasculitis with frequent coronary artery involvement, associated with coronary artery aneurysms (CAAs) even if appropriately treated. Patients with CAA have a high risk for cardiovascular complications and frequently undergo repeated coronary interventions. Coronary lesions associated with Kawasaki can be heavily calcified, presenting a therapeutic challenge. We discuss the case of a 27-year-old patient who developed CAA and severe coronary artery calcifications despite appropriate treatment after Kawasaki disease when he was two years old. The coronary stenosis was heavily calcified and failed treatment with cutting balloons, orbital atherectomy, and rotational atherectomy, but yielded after being treated with intravascular lithotripsy. The patient was treated with drug-eluting stent and covered stent to exclude the CAA, with a good final result.
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Affiliation(s)
- Teodora Donisan
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Royal Oak, USA
| | - Amy Mertens
- Department of Cardiology, Beaumont Hospital, Royal Oak, Royal Oak, USA
| | - Sayed Luay
- Department of Cardiology, Beaumont Hospital, Troy, Troy, USA
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Tsuda E, Hashimoto S. Changes in Coronary Aneurysm Diameters After Acute Kawasaki Disease from Infancy to Adolescence. Pediatr Cardiol 2021; 42:1749-1756. [PMID: 34132855 DOI: 10.1007/s00246-021-02659-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
We clarified the changes in coronary artery diameters based on the degree of coronary artery involvement immediately after acute Kawasaki disease (KD). Two hundred sixteen coronary arteries in 85 patients after KD examined by two-dimensional echocardiography were reviewed from 1995. The maximal internal diameters were measured at 2 months, 1 year, 3 years, 10 years and 15 years after KD. The coronary arteries were divided into five groups based on the absolute diameter at 2 months, as well as six groups based on the Z score at 2 months. The maximum diameters were compared at 2 months with those during follow-up in each group. The numbers of right coronary, left anterior descending, left coronary, and left circumflex arteries were 84, 73, 55 and 4, respectively. There was a significant relationship between the maximum internal diameter at 2 months and subsequent changes in the maximum diameters after KD in the late period in both groups (p < 0.0001). The maximum diameters of coronary artery aneurysms (CAAs) ≥ 8.0 mm at 2 months did not change significantly after 1 year, however, the maximum diameter of CAAs < 8.0 mm was significantly smaller in the late period (p < 0.05). Coronary arteries without dilatation at 2 months after KD grew normally. CAAs with a maximum diameter ≥ 6.0 mm and Z score ≥ 7.5 at 2 months after KD persisted in adolescents, whereas coronary arteries with diameters < 6.0 mm and Z score < 7.5 could be within normal ranges in the late period.
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Affiliation(s)
- Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1 Kishibe-shinmachi, Suita, Osaka, Japan.
| | - Shuji Hashimoto
- Department of Physiological Laboratory, National Cerebral and Cardiovascular Center, Suita, Japan
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Tsuda E, Hashimoto S. Characteristics of coronary flow velocity reserve on transthoracic Doppler echocardiography in patients with a history of Kawasaki disease. Cardiol Young 2021; 32:1-5. [PMID: 34763747 DOI: 10.1017/s104795112100439x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Whether the acute inflammation caused by Kawasaki disease will have an effect on the endothelial function of coronary arteries in the future is unknown. METHODS The coronary flow velocity reserve of the left anterior descending artery was examined by transthoracic Doppler echocardiography in 189 patients (male 125, female 64) with a history of Kawasaki disease and 10 volunteers (control). Their ages ranged from 6 to 40 years (median 22 years). The patients were divided into nine groups based on the left anterior descending artery lesions. The coronary flow velocity reserve was measured by intravenous administration of adenosine triphosphate (0.15 mg/kg/minute) while fasting. The coronary flow velocity reserve was calculated as the ratio of hyperaemic to basal mean diastolic flow velocities. The respective groups were as follows: control, no coronary artery lesions (n = 39), no coronary artery lesions in the right coronary artery (n = 29), regression (n = 11), aneurysm at the bifurcation of the left coronary artery (n = 26), aneurysm of the left anterior descending artery (n = 15), localised stenosis <75% (n = 12), localised stenosis ≥75% (n = 17), segmental stenosis (n = 5) and coronary artery bypass grafting (n = 36). One-factor ANOVA followed by Tukey's test was used to compare the coronary flow velocity reserve among the groups. RESULTS The coronary flow velocity reserve was significantly lower in the localised stenosis ≥75%, segmental stenosis and coronary artery grafting groups than in the other groups (p < 0.05). CONCLUSIONS The endothelial function in the epicoronary artery was preserved in patients with a history of Kawasaki disease and dilated coronary artery lesions.
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Affiliation(s)
- Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shuji Hashimoto
- Department of Physiological Laboratory, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Dahdah N, Kung SC, Friedman KG, Marelli A, Gordon JB, Belay ED, Baker AL, Kazi DS, White PH, Tremoulet AH. Falling Through the Cracks: The Current Gap in the Health Care Transition of Patients With Kawasaki Disease: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2021; 10:e023310. [PMID: 34632822 PMCID: PMC8751858 DOI: 10.1161/jaha.121.023310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Health care transition (HCT) is a period of high vulnerability for patients with chronic childhood diseases, particularly when patients shift from a pediatric to an adult care setting. An increasing number of patients with Kawasaki disease (KD) who develop medium and large coronary artery aneurysms (classified by the American Heart Association according to maximal internal coronary artery diameter Z‐scores ≥5 and ≥10, respectively) are becoming adults and thus undergoing an HCT. However, a poor transition to an adult provider represents a risk of loss to follow‐up, which can result in increasing morbidity and mortality. Methods and Results This scientific statement provides a summary of available literature and expert opinion pertaining to KD and HCT of children as they reach adulthood. The statement reviews the existing life‐long risks for patients with KD, explains current guidelines for long‐term care of patients with KD, and offers guidance on assessment and preparation of patients with KD for HCT. The key element to a successful HCT, enabling successful transition outcomes, is having a structured intervention that incorporates the components of planning, transfer, and integration into adult care. This structured intervention can be accomplished by using the Six Core Elements approach that is recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians. Conclusions Formal HCT programs for patients with KD who develop aneurysms should be established to ensure a smooth transition with uninterrupted medical care as these youths become adults.
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Grande Gutiérrez N, Alber M, Kahn AM, Burns JC, Mathew M, McCrindle BW, Marsden AL. Computational modeling of blood component transport related to coronary artery thrombosis in Kawasaki disease. PLoS Comput Biol 2021; 17:e1009331. [PMID: 34491991 PMCID: PMC8448376 DOI: 10.1371/journal.pcbi.1009331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 09/17/2021] [Accepted: 08/07/2021] [Indexed: 11/25/2022] Open
Abstract
Coronary artery thrombosis is the major risk associated with Kawasaki disease (KD). Long-term management of KD patients with persistent aneurysms requires a thrombotic risk assessment and clinical decisions regarding the administration of anticoagulation therapy. Computational fluid dynamics has demonstrated that abnormal KD coronary artery hemodynamics can be associated with thrombosis. However, the underlying mechanisms of clot formation are not yet fully understood. Here we present a new model incorporating data from patient-specific simulated velocity fields to track platelet activation and accumulation. We use a system of Reaction-Advection-Diffusion equations solved with a stabilized finite element method to describe the evolution of non-activated platelets and activated platelet concentrations [AP], local concentrations of adenosine diphosphate (ADP) and poly-phosphate (PolyP). The activation of platelets is modeled as a function of shear-rate exposure and local concentration of agonists. We compared the distribution of activated platelets in a healthy coronary case and six cases with coronary artery aneurysms caused by KD, including three with confirmed thrombosis. Results show spatial correlation between regions of higher concentration of activated platelets and the reported location of the clot, suggesting predictive capabilities of this model towards identifying regions at high risk for thrombosis. Also, the concentration levels of ADP and PolyP in cases with confirmed thrombosis are higher than the reported critical values associated with platelet aggregation (ADP) and activation of the intrinsic coagulation pathway (PolyP). These findings suggest the potential initiation of a coagulation pathway even in the absence of an extrinsic factor. Finally, computational simulations show that in regions of flow stagnation, biochemical activation, as a result of local agonist concentration, is dominant. Identifying the leading factors to a pro-coagulant environment in each case—mechanical or biochemical—could help define improved strategies for thrombosis prevention tailored for each patient. Computational studies aiming to model thrombosis often rely on an arterial wall injury. Collagen and other extracellular matrix components are exposed to the bloodstream, which facilitates platelet adhesion to the wall and subsequent clot formation. However, these models are not adequate to explain thrombosis in other settings where even in the absence of a focal lesion, clots may still form under certain flow conditions. Coronary artery aneurysm thrombosis following KD is an example of the need to understand the mechanisms of thrombus initiation in the absence of an extrinsic factor. This study provides a new framework to investigate thrombus initiation in KD from a patient-specific perspective, which integrates fluid mechanics and biochemistry and which could help quantify the pro-coagulant environment induced by the aneurysm and become a predictive tool. The work presented here has broad relevance to other clinical situations where flow stagnation and transport are driving factors in thrombus formation.
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Affiliation(s)
- Noelia Grande Gutiérrez
- Department of Mechanical Engineering, Stanford University, Stanford, California, United States of America
| | - Mark Alber
- Department of Mathematics and Interdisciplinary Center for Quantitative Modeling in Biology, University of California, Riverside, Riverside, California, United States of America
| | - Andrew M. Kahn
- Department of Medicine, University of California, San Diego, San Diego, California, United States of America
| | - Jane C. Burns
- Department of Pediatrics, University of California, San Diego, San Diego, California, United States of America
| | - Mathew Mathew
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brian W. McCrindle
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alison L. Marsden
- Department of Pediatrics, Bioengineering and Institute for Computational and Mathematical Engineering, Stanford University, Stanford, California, United States of America
- * E-mail:
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Salsano A, Liao J, Miette A, Capoccia M, Mariscalco G, Santini F, Corno AF. Surgical myocardial revascularization outcomes in Kawasaki disease: systematic review and meta-analysis. Open Med (Wars) 2021; 16:375-386. [PMID: 33748422 PMCID: PMC7957190 DOI: 10.1515/med-2021-0242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/05/2021] [Accepted: 02/03/2021] [Indexed: 12/18/2022] Open
Abstract
Background Kawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and early and long-term outcomes. Methods A systematic review using Medline, Cochrane, and Scopus databases was performed in February 2020, incorporating a network meta-analysis, performed by random-effect model within a Bayesian framework, and pooled prevalence of adverse outcomes. Hazard ratios (HR) and corresponding 95% credible intervals (CI) were calculated by Markov chain Monte Carlo methods. Results Among 581 published reports, 32 studies were selected, including 1,191 patients undergoing CABG for KD. Graft patency of internal thoracic arteries (ITAs), saphenous veins (SV), and other arteries (gastroepiploic artery and radial artery) was compared. ITAs demonstrated the best patency rates at long-term follow-up (HR 0.33, 95% CI: 0.17–0.66). Pooled prevalence of early mortality after CABG was 0.28% (95% CI: 0.00–0.73%, I2 = 0%, tau2 = 0), with 63/1,108 and 56/1,108 patients, undergoing interventional procedures and surgical re-interventions during follow-up, respectively. Pooled prevalence was 3.97% (95% CI: 1.91–6.02%, I2 = 60%, tau2 = 0.0008) for interventional procedures and 3.47% (95% CI: 2.26–4.68%, I2 = 5%, tau2 <0.0001) for surgical re-interventions. Patients treated with arterial, venous, and mixed (arterial plus second venous graft) CABG were compared to assess long-term mortality. Mixed CABG (HR 0.03, 95% CI: 0.00–0.30) and arterial CABG (HR 0.13, 95% CI: 0.00–1.78) showed reduced long-term mortality compared with venous CABG. Conclusions CABG in KD is a safe procedure. The use of arterial conduits provides better patency rates and lower mortality at long-term follow-up.
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Affiliation(s)
- Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, University of Genoa, L.go Rosanna Benzi, 10, 16143, Genoa, Italy.,Department of Integrated Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
| | - Jingda Liao
- Cardiovascular Research Center, University of Leicester, Leicester, United Kingdom.,Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Ambra Miette
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, University of Genoa, L.go Rosanna Benzi, 10, 16143, Genoa, Italy.,Department of Integrated Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
| | - Massimo Capoccia
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Giovanni Mariscalco
- Cardiovascular Research Center, University of Leicester, Leicester, United Kingdom.,Department of Intensive Care Medicine and Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, University of Genoa, L.go Rosanna Benzi, 10, 16143, Genoa, Italy.,Department of Integrated Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
| | - Antonio F Corno
- Houston Children Heart Institute, Hermann Children's Hospital, Houston, Texas, United States of America.,University Texas Health, McGovern Medical School, Houston, Texas, United States of America
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14
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Low-Molecular-Weight Heparin vs Warfarin for Thromboprophylaxis in Children With Coronary Artery Aneurysms After Kawasaki Disease: A Pragmatic Registry Trial. Can J Cardiol 2020; 36:1598-1607. [DOI: 10.1016/j.cjca.2020.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 12/21/2022] Open
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15
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Hu X, Wu T, Wang C, Li J, Ying C. CD248+CD8+ T lymphocytes suppress pathological vascular remodeling in human thoracic aortic aneurysms. Exp Biol Med (Maywood) 2020; 246:121-129. [PMID: 32867546 DOI: 10.1177/1535370220953386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aortic aneurysms are characterized by vascular inflammation, neovascularization, and extracellular matrix destruction of the aortic wall. Although experimental studies indicate a potential role of CD248 in microvessel remodeling, the functions of CD248 in human vascular pathologies remain unexplored. Here we aimed to study how CD248 interferes with pathological vascular remodeling of human aortic aneurysms. Immunofluorescent staining showed that CD248 expression was mainly localized in the CD8+ T cells infiltrating in the adventitia and media of aortic walls of patients with ascending thoracic aortic aneurysms. qPCR and immunofluorescent staining analyses revealed increased aortic CD248 expression and infiltrating CD248+CD8+ T cells in aortic aneurysms than in nonaneurysmal aortas. Flow cytometry analysis of human peripheral blood further identified a fraction of circulating CD248+ cells which was confined in the CD8+ T-cell compartment. The increased infiltrating of CD248+CD8+ T cells was coincident with reduced circulating CD248+CD8+ T cells in patients with ascending TAA when compared with patients with coronary artery diseases and healthy donors. The CD248+CD8+ T cells were characterized by upregulated IL-10 and downregulated IL-1β/INF-γ expression when compared with CD248-CD8+ T cells. Moreover, when co-cultured with human aortic endothelial cells, the CD248+CD8+ T cells not only downregulated endothelial expression of ICAM1/VCAM1 and MMP2/3 but also suppressed endothelial migration. This study shows that CD248 reduces pathological vascular remodeling via anti-inflammatory CD248+CD8+ T cells, revealing a CD248-mediated cellular mechanism against human aortic aneurysms.
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Affiliation(s)
- Xiaojuan Hu
- Department of Clinical Laboratory, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200090, China
| | - Ting Wu
- Renji Clinical Stem Cell Research Center, Shanghai 200127, China
| | - Chenxi Wang
- Department of Cardiovascular Surgery, School of Medicine, Shanghai Jiao Tong University, Ren Ji Hospital, Shanghai 200127, China
| | - Jun Li
- Renji Clinical Stem Cell Research Center, Shanghai 200127, China
| | - Chunmei Ying
- Department of Clinical Laboratory, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200090, China
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16
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McCrindle BW, Manlhiot C, Newburger JW, Harahsheh AS, Giglia TM, Dallaire F, Friedman K, Low T, Runeckles K, Mathew M, Mackie AS, Choueiter NF, Jone PN, Kutty S, Yetman AT, Raghuveer G, Pahl E, Norozi K, McHugh KE, Li JS, De Ferranti SD, Dahdah N. Medium-Term Complications Associated With Coronary Artery Aneurysms After Kawasaki Disease: A Study From the International Kawasaki Disease Registry. J Am Heart Assoc 2020; 9:e016440. [PMID: 32750313 PMCID: PMC7792232 DOI: 10.1161/jaha.119.016440] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Coronary artery aneurysms (CAAs) may occur after Kawasaki disease (KD) and lead to important morbidity and mortality. As CAA in patients with KD are rare and heterogeneous lesions, prognostication and risk stratification are difficult. We sought to derive the cumulative risk and associated factors for cardiovascular complications in patients with CAAs after KD. Methods and Results A 34‐institution international registry of 1651 patients with KD who had CAAs (maximum CAA Z score ≥2.5) was used. Time‐to‐event analyses were performed using the Kaplan–Meier method and Cox proportional hazard models for risk factor analysis. In patients with CAA Z scores ≥10, the cumulative incidence of luminal narrowing (>50% of lumen diameter), coronary artery thrombosis, and composite major adverse cardiovascular complications at 10 years was 20±3%, 18±2%, and 14±2%, respectively. No complications were observed in patients with a CAA Z score <10. Higher CAA Z score and a greater number of coronary artery branches affected were associated with increased risk of all types of complications. At 10 years, normalization of luminal diameter was noted in 99±4% of patients with small (2.5≤Z<5.0), 92±1% with medium (5.0≤Z<10), and 57±3% with large CAAs (Z≥10). CAAs in the left anterior descending and circumflex coronary artery branches were more likely to normalize. Risk factor analysis of coronary artery branch level outcomes was performed with a total of 893 affected branches with Z score ≥10 in 440 patients. In multivariable regression models, hazards of luminal narrowing and thrombosis were higher for patients with CAAs of the right coronary artery and left anterior descending branches, those with CAAs that had complex architecture (other than isolated aneurysms), and those with CAAs with Z scores ≥20. Conclusions For patients with CAA after KD, medium‐term risk of complications is confined to those with maximum CAA Z scores ≥10. Further risk stratification and close follow‐up, including advanced imaging, in patients with large CAAs is warranted.
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Affiliation(s)
- Brian W McCrindle
- Division of Cardiology Department of Pediatrics University of Toronto The Hospital for Sick Children Toronto Ontario Canada
| | - Cedric Manlhiot
- Division of Cardiology Department of Pediatrics University of Toronto The Hospital for Sick Children Toronto Ontario Canada
| | | | - Ashraf S Harahsheh
- Pediatrics - Cardiology Children's National Health System/George Washington University Washington DC
| | | | - Frederic Dallaire
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke Sherbrooke Quebec Canada
| | - Kevin Friedman
- Boston Children's Hospital Harvard Medical School Boston MA
| | - Tisiana Low
- Division of Cardiology Department of Pediatrics University of Toronto The Hospital for Sick Children Toronto Ontario Canada
| | - Kyle Runeckles
- Division of Cardiology Department of Pediatrics University of Toronto The Hospital for Sick Children Toronto Ontario Canada
| | - Mathew Mathew
- Division of Cardiology Department of Pediatrics University of Toronto The Hospital for Sick Children Toronto Ontario Canada
| | | | | | - Pei-Ni Jone
- Pediatric Cardiology Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Shelby Kutty
- Children's Hospital & Medical Center of Omaha NE
| | | | | | - Elfriede Pahl
- Ann and Robert H. Lurie Children's Hospital of Chicago IL
| | - Kambiz Norozi
- Department of Paediatrics Western University London Ontario Canada
| | | | | | | | - Nagib Dahdah
- Division of Pediatric Cardiology Centre Hospitalier Universitaire Ste-Justine University of Montreal Quebec Canada
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17
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Kawasaki Disease: Complex Long-term Issues for Pediatric and Adult Cardiologists. Can J Cardiol 2020; 36:1566-1568. [PMID: 32407965 DOI: 10.1016/j.cjca.2020.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/21/2022] Open
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18
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Cardiac Catheterization in Assessment and Treatment of Kawasaki Disease in Children and Adolescents. CHILDREN-BASEL 2019; 6:children6020032. [PMID: 30795614 PMCID: PMC6406834 DOI: 10.3390/children6020032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 01/09/2023]
Abstract
Cardiac catheterization has become a promising tool to assess and treat coronary artery lesions in patients with Kawasaki disease. Significant coronary artery lesions can now be treated via transcatheter route even in small children. Further development and miniaturization of this technology will help to promote widespread use to the benefit of small children suffering from coronary artery disease. The role of diagnostic and interventional coronary artery procedures in children and adolescents are discussed in this article.
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19
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Nattel S. The Canadian Journal of Cardiology: Open and Growing. Can J Cardiol 2019; 35:133-137. [DOI: 10.1016/j.cjca.2018.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 12/28/2018] [Indexed: 11/25/2022] Open
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20
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Grande Gutierrez N, Mathew M, McCrindle BW, Tran JS, Kahn AM, Burns JC, Marsden AL. Hemodynamic variables in aneurysms are associated with thrombotic risk in children with Kawasaki disease. Int J Cardiol 2019; 281:15-21. [PMID: 30728104 DOI: 10.1016/j.ijcard.2019.01.092] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/22/2018] [Accepted: 01/25/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Thrombosis is a major adverse outcome associated with coronary artery aneurysms (CAAs) resulting from Kawasaki disease (KD). Clinical guidelines recommend initiation of anticoagulation therapy with maximum CAA diameter (Dmax) ≥8 mm or Z-score ≥ 10. Here, we investigate the role of aneurysm hemodynamics as a superior method for thrombotic risk stratification in KD patients. METHODS AND RESULTS We retrospectively studied ten KD patients with CAAs, including five patients who developed thrombosis. We constructed patient-specific anatomic models from cardiac magnetic resonance images and performed computational hemodynamic simulations using SimVascular. Our simulations incorporated pulsatile flow, deformable arterial walls and boundary conditions automatically tuned to match patient-specific arterial pressure and cardiac output. From simulation results, we derived local hemodynamic variables including time-averaged wall shear stress (TAWSS), low wall shear stress exposure, and oscillatory shear index (OSI). Local TAWSS was significantly lower in CAAs that developed thrombosis (1.2 ± 0.94 vs. 7.28 ± 9.77 dynes/cm2, p = 0.006) and the fraction of CAA surface area exposed to low wall shear stress was larger (0.69 ± 0.17 vs. 0.25 ± 0.26%, p = 0.005). Similarly, longer residence times were obtained in branches where thrombosis was confirmed (9.07 ± 6.26 vs. 2.05 ± 2.91 cycles, p = 0.004). No significant differences were found for OSI or anatomical measurements such us Dmax and Z-score. Assessment of thrombotic risk according to hemodynamic variables had higher sensitivity and specificity compared to standard clinical metrics (Dmax, Z-score). CONCLUSIONS Hemodynamic variables can be obtained non-invasively via simulation and may provide improved thrombotic risk stratification compared to current diameter-based metrics, facilitating long-term clinical management of KD patients with persistent CAAs.
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Affiliation(s)
| | - Mathew Mathew
- The Hospital for Sick Children, University of Toronto, Canada
| | | | - Justin S Tran
- Department of Mechanical Engineering, Stanford University, USA
| | - Andrew M Kahn
- Department of Medicine, University of California San Diego School of Medicine, USA
| | - Jane C Burns
- Department of Pediatrics, University of California San Diego School of Medicine, USA
| | - Alison L Marsden
- Departments of Pediatrics, Bioengineering and Institute for Computational and Mathematical Engineering, Stanford University, USA.
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21
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McCrindle BW, Harris KC. Coronary Artery Aneurysms After Kawasaki Disease: Understanding the Pathology. Can J Cardiol 2018; 34:1094-1097. [DOI: 10.1016/j.cjca.2018.07.412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 11/24/2022] Open
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