Distribution of Kawasaki Disease Coronary Artery Aneurysms and the Relationship to Coronary Artery Diameter.

We investigated how the diameter of coronary artery aneurysm (CAA) relates to the distribution immediately after Kawasaki disease (KD). Two hundred and four pts (155 males and 49 females) who had undergone selective coronary angiography (CAGs) less than 100 days after the onset of KD were studied. We measured the maximum diameter of each artery segment in the initial CAGs. We analyzed the relationship between the maximum diameters and the distribution of CAA. We divided the patients into four groups based on the maximum CAA diameter in each patient (large(L) ≥8 mm, medium(M) ≥6 and <8 mm, small(S) ≥4 and <6 mm, very small(VS) <4 mm) and counted the affected segments. There were 87, 61, 36, and 20 patients in groups L, M, S, VS, respectively. The number of segments with CAA in each group was L 6 ± 2, M 4 ± 2, S 2 ± 2, VS 2 ± 1. The number of affected segments in L was significantly more than M, and a large value for L indicated that involvement was significantly more likely to be bilateral. The larger the maximum diameter of CAA, the more extensive disease involvement and the more likely to be bilateral. A large maximum CAA can also indicate coronary involvement in the longitudinal directions. It is an important charcteristic in distribution of CAA caused by KD vasculitis.

Long-term patency of internal thoracic artery grafts for coronary artery stenosis due to Kawasaki disease: comparison of early with recent results in small children.

BACKGROUND: The results of coronary artery bypass grafting using the internal thoracic artery (ITA) had been reported less satisfactory in patients < 12 years old with coronary artery lesions caused by Kawasaki disease. METHODS: Since 1983, 67 patients have undergone this operation in our hospital; their age at operation ranged from 1 to 59 years (median 11 years), and the total number of ITA grafts was 95. The interval from operation to latest graft patency as confirmed by angiogram or echocardiogram ranged from 4 months to 23 years (median 8 years). For analysis of graft patency rates, patients were divided into 4 groups based on year of coronary artery bypass grafting and age when grafted. The groups based on year were from 1983 to 1993 (early) and from 1994 to 2006 (later), whereas the age groups were age at operation < 12 years and age at operation > or = 12 years. From 1999, percutaneous transluminal balloon angioplasty was performed for postoperative anastomotic stenosis. RESULTS: Percutaneous transluminal balloon angioplasty for anastomotic stenosis in ITA graft was performed in 6 patients. When the age at operation was < 12 years, the 10-year patency rate in the later period was 94.4% (n = 18), significantly > the 70.0% (n = 30) seen in the earlier period (P < .05). CONCLUSION: Recent results of ITA grafts in patients < 12 years old have improved through the application of appropriate indications and percutaneous transluminal balloon angioplasty for anastomotic stenosis. Once good flow in the ITA 1 year after surgery is confirmed, graft patency will persist > 20 years.

Hybrid therapy for rapid enlargement of hibernating coronary arteriovenous fistulas.

The use of hybrid therapy for recurrent multiple coronary arteriovenous fistulas in a 56-year-old woman is reported. The patient underwent surgical closure of a coronary arteriovenous fistula of the right coronary artery under cardiopulmonary bypass at 47 years of age. Reoperation was required 9 years later for recurrence of the same fistula. It was divided under a beating heart. Early postoperative angiography showed complete occlusion of the right coronary fistula. However, hibernating fistulas of the left circumflex artery, which had been left untouched because of insignificant shunt with no remarkable change for 9 years, increased in size rapidly. Transcatheter embolization was successfully performed for these residual fistulas.

Coil occlusion of patent ductus arteriosus.

BACKGROUND: Coils are the only devices available for transcatheter occlusion of patent ductus arteriosus (PDA) in Japan. Since April 1999, we have introduced a 0.052-inch Gianturco coil (0.052-inch coil) to close PDA >or=2.5 mm. METHODS AND RESULTS: A retrospective survey of the outcome of coil occlusions for PDA >or=2.5 mm before and after the 0.052-inch coil became available found that (1) the frequency of PDA >or=2.5 mm among all candidates for coil occlusion significantly increased after the availability of a 0.052-inch coil (p<0.01); (2) deployment complicated by migration (p<0.01), and prolonged procedure time (p<0.05) were significantly decreased after the introduction of the 0.052-inch coil. In a multivariate logistic regression model for uneventful deployment adjusted for age, pulmonary to systemic flow ratio, and use of a 0.052-inch coil, use of the 0.052-inch coil significantly decreased eventful deployment (p<0.05); and (3) successful deployment of a coil for PDA >or=4 mm significantly increased with the 0.052-inch coil (p<0.01). Complete occlusion was achieved once deployment was successful. CONCLUSION: Introduction of the 0.052-inch coil decreased complicated coil occlusion deployment for PDA >or=2.5 mm, and contributed to a better likelihood of coil occlusion for PDA >or=4 mm.

Late distortion of the original Palmaz stent implanted in postoperative lesions associated with congenital heart disease.

The objective of this study was to report late distortion of a Palmaz stent. Late distortion of an original Palmaz stent, implanted in an extracardiac lesion, is rare. We completed a 1-year follow-up of 54 patients who had been implanted with 80 Palmaz stents in extracardiac lesions. Distortion of two stents was detected in two patients. For case 1, we implanted a P188 stent for supravalvar pulmonary stenosis complicating an arterial switch operation in a 14-year-old girl. Seven months later, we found compression of the stent. Although we implanted two P308 stents anterior to the distorted stent, distortion of both stents developed after 1 month. Two more P308 stents placed inside each stent were gradually recompressed. A CAT scan showed compression of the stent by a dilated sinus of valsalva. For case 2, we implanted a P308 stent for stenosis of the superior vena cava after Williams operation in an 11-year-old boy. A chest X-ray documented longitudinal compression of the stent 27 months after implantation and a CAT scan showed the ascending aorta was in contact with the stent. A Palmaz stent may be distorted when implanted in a lesion adjacent to a pulsating aorta.

Consequence of atrial fibrillation and the risk of embolism after percutaneous mitral commissurotomy: the necessity of the maze procedure.

BACKGROUND: We sought to investigate the incidence and risk of embolism after percutaneous balloon mitral commissurotomy (PMC) and delineated the necessity of the maze procedure in patients with atrial fibrillation (AF). METHODS: Clinical records of 326 patients, who underwent PMC between April 1988 and March 2003, and 162 patients, who underwent mitral valve surgery (MVS) combined with the maze procedure (MVS/maze) in the same period, were reviewed. We examined the consequence of cardiac rhythm and the incidence and risk of embolism after PMC. Next our current criteria for indication of the maze procedure, which included duration of AF less than 10 years, voltage of f wave on electrocardiography greater than 0.1 mV, cardiothoracic ratio less than 70%, and left atrial dimension less than 70 mm, were applied to all patients. These criteria were satisfied by 190 patients of PMC (PMC group) and 114 patients of MVS/maze (MVS/maze group) and the early and late results of the two groups were compared. RESULTS: Thirty-eight patients suffered from embolic complications after PMC. Of these 33 patients experienced AF before intervention. The actuarial embolism-free rate at 10 years was 81.9% in patients with AF before PMC and 92.9% in patients with sinus rhythm before PMC (p = 0.01). Univariate predictors of embolism after PMC included previous embolic history (p = 0.01), AF (p = 0.01), pressure gradient (p = 0.01), age (p = 0.03), and mitral valve area (p = 0.04). Multivariate analysis identified AF as the independent predictor of embolism in the late follow-up period (p = 0.03). In a comparative study of the selected patients the actuarial AF-free rates after MVS/maze were 89.9% at 1 year and 85.7% at 5 years and were significantly higher than those of 17.3% at 1 year and 4.2% at 5 years after PMC (p < 0.0001). The actuarial embolism-free rate in the MVS/maze group was 98.0% at 5 years and was significantly higher than that of 84.8% at 5 years and 82.4% at 10 years in the PMC group (p = 0.01). CONCLUSIONS: PMC alone is not sufficient with regard to sinus rhythm recovery and prevention of embolism. Surgical treatment concomitant with the maze procedure may be beneficial for patients with AF.

A small pulmonary arteriovenous malformation as a cause of recurrent brain embolism.

We report a case of recurrent paradoxical brain embolism mediated through a small pulmonary arteriovenous malformation (PAVM) with a 1.8-mm-diameter feeding artery. In this case, the further recurrent stroke was prevented successfully by PAVM embolization. Although embolization therapy is currently recommended only for PAVMs with feeding arteries greater than 3 mm in diameter, the therapy may be needed also in the smaller PAVMs.

Balloon angioplasty of postoperative coarctation in the transverse arch in infants: protecting the common carotid artery.

We performed balloon angioplasty in three patients with postoperative coarctation in the transverse arch adjacent to the left common carotid artery. The age at arch reconstruction was 5, 6, and 2 days, while the interval between operation and balloon dilatation was 59 days, 87 days, and 12 months, respectively. Two balloons, one in the stenosis and the other in the left common carotid artery, were introduced over a wire sequentially and inflated simultaneously until the waist of the balloon in the arch disappeared. After balloon dilatation, a significant reduction in the peak-to-peak pressure gradient and an increase in vessel diameters were observed in all patients. Further growth of the transverse arch was documented at follow-up in two patients. No aneurysm has been detected in any patients. We believe that placing a protective balloon in the neck vessel increases safety during balloon dilatation of coarctation in the transverse arch.

Stent implantation and subsequent dilatation for pulmonary vein stenosis in pediatric patients: maximizing effectiveness.

The outcome of stent implantation and redilatation was investigated in 4 pediatric patients with 7 stenotic lesions of the pulmonary vein (PV), paying particular attention to late neointimal proliferation. The minimal diameter of the lesions increased from 0.8-3.6 (2.3+/-1.1) mm to 3.6-8.4 (5.1+/-1.6) mm immediately after stent implantation. Although the pressure gradient across the lesion was not measured in patient 4, in patients 1-3, it decreased from 4-34 (18+/-13) mmHg to 3-15 (7+/-4) mmHg. Except for case 4, who achieved a lesion diameter of 8.4 mm after initial stent dilatation, the other 6 lesions all restenosed within a few months, with an increasing pressure gradient. One patient with multiple PV stenoses associated with persistent severe pulmonary hypertension died suddenly. However, repeat dilatations were effective in all other lesions. Furthermore, in one lesion in patient 1, no serious restenosis developed for 20 months after the lesion was dilated up to 5.6 mm. Although further follow-up is mandatory, the final stent diameter within a vessel may determine long-term patency, and aggressive redilatation may be crucial for successful therapy of such a difficult disease.

Acute recoil of stents used for the relief of stenotic great vessels in the setting of congenital cardiac disease.

We implanted either large or medium Palmaz stents, or a Palmaz Corinthian stent, in various stenotic vessels, such as the pulmonary arteries, pulmonary veins, aorta, or superior caval vein. Using angiograms, we measured the diameter of the stenotic vessel before or after the implantation, the minimal diameter of the lumen, the minimal diameter of the largest fully expanded balloon used to expand the stent, and the diameter immediately after withdrawal of the balloon. The minimal diameter of the fully expanded balloon, and the minimal diameter of the lumen subsequent to expansion, were 8.2 +/- 2.4, and 7.7 +/- 2.3 mm, giving an absolute recoil of 0.5 +/- 0.4 mm, and a proportional recoil of 7 +/- 4%. There was no significant difference in either the absolute or proportional recoil for any of the stents, or for any of the different stenotic vessels. The proportional recoil correlated linearly with the minimal diameter of the lumen prior to the procedure, and with the ratio of the stenosis to the balloon, while the diameter of the stenotic vessels, the minimal diameter of the largest fully expanded balloon, the proportional stenosis prior to the procedure, and the ratio of the balloon to the diameter of the stenotic vessel, had no significant correlation with proportional recoil. The proportional recoil exceeded more than one-tenth when the minimal diameter of the lumen prior to the dilation was less than 3 mm, or the ratio of the balloon to the stenosis was greater than 3.0. An absolute recoil of around 1 mm is common when a large or medium Palmaz, or a Palmaz Corinthian stent, is implanted in great vessels. Balloons with a diameter of approximately one-tenth greater than that of the adjacent vessel may be needed if the minimal diameter of the lumen is small prior to the procedure.

Potential goals for the dimensions of the pulmonary arteries and aorta with stenting after the Fontan operation.

The purpose of this study was to clarify desired stent sizes for stenotic lesions in the post-Fontan circulation. Using angiograms from 22 patients before and at late follow-up (> or = 15 years) after the Fontan operation, we measured the maximum diameters of the proximal pulmonary arteries (PA) and the descending aorta. The diameters of the PA ipsilateral to the inferior vena cava, contralateral to the inferior vena cava, and descending aorta after the Fontan were 10.6-22.6 (15.8 +/- 3.3), 8.0-19.1 (12.9 +/- 3.1), and 12.1-18.9 (15.8 +/- 2.0) mm, respectively, while the percent of normal predicted diameters (% N) were 55%-104% (70% +/- 14%), 38%-99% (66% +/- 17%), and 46%-74% (60% +/- 7%), respectively. Despite somatic growth, the % N of all vessel diameters decreased significantly after the Fontan operation. In conclusion, smaller-sized stents should be acceptable for both the pulmonary artery and descending aorta in the Fontan circulation.

Late neointimal proliferation following implantation of stents for relief of pulmonary arterial stenosis.

On the assumption that the diameter of the reference vessel might determine the thickness of neointimal coverage of stents placed in the pulmonary arteries, we analyzed the angiograms of 28 lesions in 17 patients who underwent follow-up cardiac catheterization. Excluding 2 lesions where late stenosis was determined mainly by recoil of greater than 30%, we investigated the neointimal thickness of 26 lesions in 16 patients. Several factors that might contribute to late re-stenosis were also analyzed. Age and body weight at implantation ranged from 0.8 to 20 years, with a median of 6 years, and from 6.8 to 77.5 kg, with a median of 17.6 kg. Follow-up interval was from 6 to 15 months, with a median of 6 months. There was a significant increase in diameter, as well as a reduction in pressure gradient, immediately after the implantation of stents. Although there was no significant difference between the achieved diameter and the diameter of the stent at follow-up, the diameter of the lesion at follow-up was significantly smaller than the diameter achieved by stenting. The increase in the pressure gradient at follow-up was slightly greater in 4 lesions where the late reduction in diameter was greater than 30% than in the 18 lesions where this was less than 30% (p = 0.05). The diameter of the reference vessel, and the diameter by stenting correlated with the late reduction in diameter. All lesions with diameter reduced greater than 30% had a reference diameter of less than 6.1 mm, and a diameter achieved by stenting of less than 6.5 mm. Late loss in luminal diameter directly correlated with the thickness of the neointimal coverage. In conclusion, close observation should be mandatory following implantation of stents in small pulmonary arteries.

Factors determining peripheral pulmonary artery stenosis remodeling in children after percutaneous transluminal balloon angioplasty.

The peripheral pulmonary artery stenosis (PPS) that complicates congenital heart anomalies can improve after percutaneous transluminal balloon angioplasty (PTA), despite an initial poor response, but there is little information concerning the factors that determine such remodeling. The present study reviewed the hemodynamic and angiographic data before, immediately after, and at late follow-up after PTA for 17 lesions in 14 patients. Lesions were classified into either the (+) group (with pulmonary artery remodeling) or the (-) group (without remodeling). Remodeling was defined as an increase of more than 30% in the predictive percent of normal (%N) of the peripheral pulmonary artery diameter at late follow-up compared with the diameter immediately after PTA. Remodeling occurred in 6 of 17 lesions (35%), and the pressure gradient immediately after PTA was significantly smaller (<10 mmHg) in the (+) group than in the (-) group. Late expansion of the lesion (remodeling) occurs after PTA in some children with PPS and an adequate initial reduction in the pressure gradient favors subsequent remodeling.