Intimal thickening and disruption of the media occur in the arterial walls of coronary arteries not associated with coronary arterial aneurysms in patients with Kawasaki disease

Successful non-invasive imaging of the coronary artery IMT in pediatric patients with Kawasaki disease using high-resolution echocardiography

Kawasaki Disease (KD) is a multisystemic vasculitis of medium- and small-sized arteries. Abnormal intimal thickening may develop in the involved arterial area after regression of coronary artery aneurysm (CAA). Intimal dysfunction may induce local stenosis or arteriosclerosis in the future. In this case-control study, we investigated 29 consecutive KD patients [20 male, median current age, 7.9 years; median follow-up duration, 5.7 years] and a group of 29 healthy matched controls (CON) [19 male, median current age, 10.8 years]. They were assesed and compared for CAA, LVFS, GCS, GLS, coronary artery (CA) Z scores, carotid intima-media thickness (IMT) and coronary artery IMT by high-resolution transthoracic echocardiography (hrTTE). Coronary artery IMT (caIMT) was significantly higher in patients with a maximal CA Z score > 2.5 in acute KD than in CON: KD caIMT: 0.62 mm [IQR, 0.57-0.72 mm] vs. 0.53 mm [0.51-0.60 mm], p = 0.043. CAAs were found in 15 (51.7%) patients with acute KD. The maximal median LCA Z score in acute KD was 2.57z [IQR, 1.93-3.2z] and in follow-up -0.39z [IQR, -1.25 to -0.36z]. There was no significant difference in carotid IMT between KD patients and CON. Signs of CA intima-media thickening were detected by hrTTE in patients with a maximal CA Z score > 2.5 in acute KD. These data indicate that these patients may be at risk for cardiovascular sequale even in the absence of permanent CA luminal abnormalities. Therefore long-term follow-up of this group of KD patients may be required.

Pathological Alterations of Coronary Arteries Late After Kawasaki Disease: An Optical Coherence Tomography Study

Background

The long-term impact of Kawasaki disease on coronary arteries in vivo is unclear.

Objectives

The purpose of this study was to investigate coronary arteries in the late convalescent phase, we followed patients with Kawasaki disease who developed coronary artery aneurysms (CAAs).

Methods

We followed 24 patients and used optical coherence tomography at a median of 16.6 years after the onset of Kawasaki disease.

Results

Of 72 coronary arteries, optical coherence tomography was performed on 61 arteries: 17 with a persistent CAA, 29 with a regressed CAA, and 15 without a CAA. Between-group comparison was performed by chi-square or Fisher's exact test, and intimal thickening (17 vs 29 vs 15, all 100%, P = NA) and medial disruption (17 [100%] vs 29 [100%] vs 14 [93%], P = 0.25) were commonly observed in the investigated arteries. Advanced features of atherosclerosis were more frequently seen in arteries with persistent CAAs than in those with regressed CAAs and in those without CAAs: calcification (12 [71%] vs 5 [17%] vs 1 [7%], P < 0.001), microvessels (12 [71%] vs 10 [35%] vs 4 [27%], P = 0.020), cholesterol crystals (6 [35%] vs 2 [7%] vs 0 [0%], P = 0.009), macrophage accumulation (11 [65%] vs 4 [14%] vs 4 [27%], P = 0.002), and layered plaque (8 [47%] vs 11 [38%] vs 0 [0%], P = 0.004).

Conclusions

Long after onset of Kawasaki disease, all arteries showed pathological changes. Arteries with persistent CAAs had more advanced features of atherosclerosis than those with regressed CAAs and those without CAAs.

When two Z-scores meet-analysis of exercise capacity of children and adolescents with Kawasaki disease by a new Z-score model of coronary artery and a new Z-score evaluating peak oxygen consumption : Coronary artery Z-score and peakVO2 Z-score in KD

BACKGROUND

Coronary artery (CA) Z-score system is widely used to define CA aneurysm (CAA). Children and adolescents after acute stage of Kawasaki disease (KD-CA) have a higher risk of developing CAAs if their CA Z-score ≥ 2.5. Z-score system of peak oxygen consumption (Peak VO2 Z-score) allows comparisons across ages and sex, regardless of body size and puberty. We aimed to compare the exercise capacity (EC) indicated by peak VO2 Z-score during cardiopulmonary exercise testing (CPET) directly between KD-CA with different CA Z-score.

METHODS

KD-CA after acute stage who received CPET in the last 5 years were retrospectively recruited. CA Z-score was based on Lambda-Mu-Sigma method. Max-Z was the maximum CA Z-score of different CAs. KD children with Max-Z < 2.5 and ≥ 2.5 were defined as KD-1 and KD-2 groups, respectively. Peak VO2 Z-score was calculated using the equation established based on Hong Kong Chinese children and adolescent database.

RESULTS

One hundred two KD-CA were recruited (mean age: 11.71 ± 2.57 years). The mean percent of measured peak VO2 to predicted value (peak PD%) was 90.11 ± 13.33. All basic characteristics and baseline pulmonary function indices were comparable between KD-1 (n = 87) and KD-2 (n = 15). KD-1 had significantly higher peak VO2 Z-score (p = .025), peak PD% (p = .008), peak metabolic equivalent (p = .027), and peak rate pressure product (p = .036) than KD-2.

CONCLUSIONS

KD-CA had slightly reduced EC than healthy peers. KD-CA with Max-Z ≥ 2.5 had significantly lower peak EC than those < 2.5. Max-Z is potentially useful follow-up indicator after acute stage of KD.

COVID-19-Associated Multisystem Inflammatory Syndrome in a Neonate with Atypical Coronary Artery Involvement

OBJECTIVE

The study aimed to report a novel coronavirus disease 2019 (COVID-19)-associated multisystem inflammatory syndrome in children (MIS-C) in a neonate found to have an atypical diffuse thickening in coronary artery walls whose diagnosis required a multi-imaging approach.

STUDY DESIGN

A neonate presented at birth with multiple organ involvement and coronary artery anomalies. A diagnosis of MIS-C associated with COVID-19 was supported by maternal severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy, and by the presence of both immunoglobulin (Ig)-G against SARS-CoV-2 and spike-specific memory B-cells response in the neonatal blood. Other plausible causes of the multiple organ involvement were excluded.

RESULT

At admission, a severe coronary artery dilatation was identified on echocardiography, supporting the diagnosis of the MIS-C Kawasaki-like disease; however, coronary artery internal diameters were found to be normal using cardiac computed tomography angiography. At discharge, comparing the two imaging techniques each other, the correct diagnosis resulted to be an abnormal thickening in coronary arterial walls. These findings suggest that the inflammatory process affecting the coronary arterial wall in MIS-C could result not only in typical coronary artery lesions such as dilatation of the lumen or aneurysms development but also in abnormal thickening of the coronary artery wall.

CONCLUSION

Our case provides an alert for pediatric cardiologists about the complexity to assess coronary artery involvement in MIS-C and raises the question that whether an abnormal vascular remodeling, with normal inner diameters, is to be considered like coronary artery dilatation for risk stratification.

KEY POINTS

· COVID-19 associated MIS-C can present in neonates with multiple organ involvement.. · Coronary artery assessment in neonatal MIS-C could be complex, and a multi-imaging approach could be required.. · Beside the typical coronary artery lesions, such as dilatation of the lumen or aneurysms, also abnormal thickening of the coronary artery wall can occur..

Analysis of Age, Sex, Lack of Response to Intravenous Immunoglobulin, and Development of Coronary Artery Abnormalities in Children With Kawasaki Disease in Japan

IMPORTANCE

Initial intravenous immunoglobulin (IVIG)-refractory status and prolonged fever are established risk factors for the development of coronary artery abnormalities (CAAs) among patients with acute-phase Kawasaki disease (KD). However, whether different risk factors exist for initial unresponsiveness to IVIG and CAA development remains unclear.

OBJECTIVE

To evaluate whether different risk factors exist for initial unresponsiveness to IVIG and CAA development among patients with KD (stratified by age at disease onset).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included a consecutive sample of 2414 patients from a database of patients with KD from October 1, 1999, to September 30, 2019. The data were based on annual surveys (response rate, 100%) using hospital medical records across Wakayama Prefecture, Japan. Data were analyzed from March 6 to March 26, 2022.

EXPOSURES

The patient's age and diagnosis of KD by board-certified pediatricians using the criteria established by the Japan KD Research Committee.

MAIN OUTCOMES AND MEASURES

Initial unresponsiveness to IVIG, defined as treatment with optional or advanced therapies, and development of CAAs. Echocardiograms performed 1 month after KD onset using the Japanese Ministry of Health criteria evaluated the presence or absence of CAAs. Odds ratios (ORs) with 95% CIs of patient age at KD onset for unresponsiveness to IVIG and developing CAAs were calculated using multivariable logistic regression models.

RESULTS

A total of 2414 patients (1403 male patients [58.1%]; median age at onset of KD, 25 months [range, 1-212 months]) were included in the study: 550 younger than 12 months, 1342 aged 12 to 47 months, and 522 older than 47 months. A total of 535 patients (22.2%) received optional or advanced treatment and 68 patients (2.8%) developed CAAs 1 month after disease onset. The sex-adjusted OR among patients younger than 12 months for unresponsiveness to IVIG was 0.77 (95% CI, 0.59-0.99) and for development of CAAs was 1.94 (95% CI, 1.07-3.52); among those older than 47 months, the OR for unresponsiveness to IVIG was 1.32 (95% CI, 1.05-1.67) and for development of CAAs was 2.47 (95% CI, 1.39-4.39). After adjusting for IVIG administration, ORs among boys older than 47 months for unresponsiveness to IVIG was 1.14 (95% CI, 0.84-1.56) and for development of CAAs was 2.15 (95% CI, 1.08-4.30); among girls younger than 12 months, the OR for unresponsiveness to IVIG was 1.02 (95% CI, 0.65-1.60) and for development of CAAs was 3.79 (95% CI, 1.21-11.90).

CONCLUSIONS AND RELEVANCE

The results of this study suggest that risks of unresponsiveness to IVIG and the development of CAAs differ between infants with KD and older patients with KD. Residual risk factors for KD-related CAAs other than initial unresponsiveness to IVIG should be addressed, particularly in infants.

Serial Exercise Testing and Echocardiography Findings of Patients With Kawasaki Disease

OBJECTIVE

Kawasaki disease (KD) is the most common form of pediatric vasculitis. We evaluated the influence of KD on cardiopulmonary function and analyzed the echocardiographic findings of patients with KD through serial follow-ups from childhood to adolescence.

METHODS

This was a retrospective study. We recruited patients with KD after the acute stage who underwent at least two (with >1-year interval between visits) cardiopulmonary exercise testing (CPET) and echocardiographic examinations in the last 10 years. Cardiopulmonary function was determined through CPET on a treadmill. The maximum Z score (Max-Z) of the proximal left anterior descending coronary artery or right coronary artery was determined using echocardiography. Healthy peers matched for age, sex, and body mass index with serial CPET and echocardiographic data were recruited as a control group.

RESULTS

Each group consisted of 30 participants with comparable basic characteristics. No significant differences in the variables of the first CPET were observed between the two groups. In the final CPET, the control group had a higher percentage of measured oxygen consumption (Vo₂) at the anaerobic threshold (AT) to the predicted peak Vo₂ (p = 0.016), higher percentage of measured peak Vo₂ to the predicted peak Vo₂ (p = 0.0004), and higher Vo₂ at AT (p < 0.0001) than those of the KD group. No significant difference in the percentage of distribution of Max-Z was observed between the first and final echocardiographic examinations.

CONCLUSIONS

Children with a history of KD had comparable exercise capacity to their healthy peers. However, in the follow-up, the aerobic metabolism and peak exercise load capacities of adolescents with KD were significantly lower than those of control adolescents.

Status of treatment and outcome in Kawasaki disease in the Kinki area of Japan

BACKGROUND

The treatment guidelines for acute Kawasaki disease (KD) have been revised several times. Moreover, the criterion used to define coronary artery abnormalities (CAAs) has changed from the coronary artery's internal diameter to the Z-score. Treatment for KD and methods for evaluating CAAs vary between hospitals, so we investigated the actual status of acute KD treatment and development of CAAs under the 2012 Japanese treatment guidelines for acute KD.

METHODS

The 24th Japanese Nationwide Survey on Kawasaki Disease yielded 2618 patients who developed KD in the Kinki area in 2016. We sent a secondary questionnaire to each participating hospital and used the resulting data to investigate the frequency of CAAs according to Z-score, treatment by KD treatment stage, and predictors of CAAs.

RESULTS

The response rate was 80.0%. The data for 1426 patients without major data deficiencies were examined. The frequency of CAAs was 3.0% when based on coronary artery internal diameters and 8.8% when based on Z-scores. Intravenous immunoglobulins combined with corticosteroids were administered as an initial treatment in 12.8% of cases and as a second-line treatment in 16.8% of cases. Corticosteroids, cyclosporine A, infliximab, and plasma exchange were used at similar frequencies for third-line treatment. A pretreatment maximum coronary artery Z-score of ≥1.9 and age <1 year were associated with significantly higher incidences of CAAs.

CONCLUSIONS

Using the Z-score resulted in a threefold increase in the number of patients diagnosed with CAAs. A pretreatment maximum coronary artery Z-score of ≥1.9 and age <1 year are useful predictors of CAAs.