Prevalence of antecedent Kawasaki disease in young adults with suspected acute coronary syndrome in high incidence cohort.

Background: Acute coronary syndrome (ACS) in early adulthood (<40 years old) may be associated with unrevealed diagnoses of Kawasaki disease (KD) in childhood. Daniels et al. showed that 5% of young adults with acute coronary syndrome might have antecedent Kawasaki disease in a cohort with Kawasaki disease incidence rates ranging from about 9 to 20 per 100,000 children under 5 years of age. However, there is no relevant research from the cohort with higher incidence rates (>80-100 per 100,000 children under 5 years of age) of Kawasaki disease. Methods: We conducted a multicenter, retrospective study by reviewing medical records and angiographic data from two institutions (middle and southern Taiwan, respectively) of adults <40 years of age who underwent coronary angiography for clinically suspected acute coronary syndrome (2009-2019). Angiographic images were independently analyzed by three cardiologists who were blinded to the medical records. Demographic and laboratory data and risk factors of coronary artery disease were integrated to assess the likelihood of antecedent KD. Results: All 323 young adults underwent coronary angiography, and 27 had coronary aneurysms. The patients' clinical and angiographic characteristics were evaluated, and 7.4% had aneurysms likely to be associated with KD. Most subjects were male (23/24), and their low-density lipoprotein (LDL) levels were significantly higher (p = 0.028) than those of subjects unlikely to have KD. Conclusion: This study proposed that the cohort with higher Kawasaki disease incidence rates may have a higher prevalence of young adult ACS associated with antecedent KD. The importance of determining the clinical therapeutic significance of antecedent Kawasaki disease in young adult ACS warrants advanced research. Higher LDL levels may have a long-term cardiovascular impact in KD patients with persistent coronary aneurysms.

Case report: The impact of percutaneous atrial septal defect closure in pulmonary hypertension with co-existing cor triatriatum sinister and multiple cardiac comorbidities.

Cor triatriatum sinister is a rare congenital anomaly characterized by the left-sided triatrial form of the heart. Diverse theories have been proposed regarding its formation, and the failure of incorporation of the common pulmonary vein into the left atrium (LA) during embryogenesis is the most widely accepted theory. Accordingly, cor triatriatum sinister may be associated with pulmonary venous obstruction and post-capillary pulmonary hypertension in the setting of restricted fenestration. A high proportion of patients with cor triatriatum sinister also have an associated secundum atrial septal defect. Pre-capillary pulmonary hypertension, which is unusual in patients with small atrial septal defects (<2 cm), is probably not as rare as some reports indicate, especially when combined with complex comorbidities. The conventional treatment strategy of atrial septal defect closure in patients with pulmonary hypertension, whether associated with cor triatriatum sinister or co-existing multiple cardiac anomalies, involves simultaneous repair with other cardiac surgical procedures. To the best of our knowledge, there is no reported clinical experience of percutaneous atrial septal defect closure in the literature. Herein, we present the case of an elderly female with pulmonary hypertension and coexisting cor triatriatum sinister, secundum atrial septal defect, and multiple cardiac anomalies. Despite optimal medical therapy, the biventricular failure deteriorated, and clinical stabilization could not be achieved. Transcutaneous atrial septal defect closure was then performed. Subsequent investigations showed an initial improvement (perhaps due to elimination of the left-to-right shunt) from this intervention, but the long-term impact did not appear favorable, likely due to multiple uncorrected cardiac anomalies. To the best of our knowledge, this is the first clinical report showing that partial treatment of combined pre- and post-capillary pulmonary hypertension by eliminating the pre-capillary component may have an initial benefit; thus, total surgical correction should be considered a definite therapeutic strategy unless contraindicated.

Transthoracic echocardiography monitoring during ASD closure using an artificial hand system.

AIM: Continuous real-time echocardiographic monitoring is essential for guidance during ASD closure. However, transthoracic echocardiography (TTE) can only be implemented intermittently during fluoroscopy. We evaluate a novel approach to provide real-time imaging during the entire procedure. FINDING: We developed a custom-made TTE monitoring apparatus using artificial hand (AH-TTE) that enables real-time TTE images during atrial septal defect (ASD) closure. Thirty-two patients underwent successful device implantation using AH-TTE monitoring without complications. The median duration for real-time AH-TTE monitoring was 22 min and the median fluoroscopy time was 7.2 min. One case of pericardial effusion and one of transient bradycardia event due to air embolism was detected. All patients had uneventful recoveries. CONCLUSIONS: Our simple and novel monitoring technique with AH-TTE provides TEE-like monitoring and may be a new alternative method for ASD closure. It gives real-time stable TTE images and minimizes radiation exposure for the interventional team during fluoroscopy.

Initial experience of transcatheter closure of subarterial VSD with the Amplatzer duct occluder.

BACKGROUND: The traditional treatment of subarterial ventricular septal defect (VSD) is open heart surgery. This study aimed to evaluate the feasibility, safety and outcome of transcatheter closure with the Amplatzer duct occluder (ADO). METHODS: Between March 2012 and June 2015, a total of 16 patients (8 male and 8 female) with subarterial VSD who underwent transcatheter closure with the ADO were enrolled retrospectively. Their age ranged from 3.0 to 65.6 years, with the median of 35.6 years; their body weights ranged from 14 to 92 kg with the median of 60 kg. All patients had prolapse of the right coronary cusp without subaortic rim. Mild aortic regurgitation was noted in 11 (69%) patients. RESULTS: Left ventriculogram showed VSD size ranged from 1.3 to 9.3 mm with the median of 3.5 mm. The device was successfully implanted in 88% (14/16) of the patients. Although one patient had mild skin allergy to contrast medium, no other complication was noted. Complete closure rate was 64%, 86%, 86% and 86% at 1-day, 1-month, 6-month and 12-month follow-up, respectively. Two patients developed new or worsening aortic regurgitation during follow-up. CONCLUSION: Transcatheter closure of subarterial VSD with ADO is technically feasible and safe in patients older than 7 years of age. However, development or worsening of aortic regurgitation requires long-term follow-up.

Transcatheter device closure of postmyocardial infarction ventricular septal defect.

BACKGROUND: Transcatheter device closure of postmyocardial infarction ventricular septal defect (PMIVSD) is less invasive than surgical repair. However, its feasibility, timing, outcome, and prognostic factors remain unclear. METHODS: This was a multicenter, retrospective cohort study. Between February 2012 and July 2015, a total of 10 (8 male and 2 female) patients with PMIVSD undergoing attempted device closure were enrolled retrospectively. The procedures were performed under general anesthesia with fluoroscopic and transesophageal echocardiographic guidance. RESULTS: The patients enrolled in the study were in the age range 50-85 years (median age of 76.5 years). The interval from infarction to device closure ranged from 6-147 days, with the median of 12 days. A total of 13 devices were implanted in 10 patients. There were five Amplatzer muscular ventricular septal defect occluders, four Amplatzer septal occluders, three Amplatzer PMIVSD occluders and one Amplatzer vascular plug II. Complications included transient ventricular tachycardia in three patients, device embolization in one patient, and tracheal bleeding in one patient. No procedure-related death, stroke, or cardiac tamponade was noted. During follow-up, two patients died of heart failure and two patients died of sepsis. Overall, subjects with age ≥ 80 years, systolic blood pressure ≤ 90 mmHg, and procedure time ≥180 minutes were significant predictor factors for mortality. All patients with the interval of infarction to device closure >12 days survived. CONCLUSION: Our findings indicate that transcatheter device closure of PMIVSD is technically feasible, safe, and effective to reduce the shunt. The crucial prognostic factors were ascertained to be age ≥ 80 years, systolic blood pressure ≤ 90 mmHg, and procedure time ≥180 minutes.