A previously healthy 6-month-old boy suddenly collapsed at home, requiring cardiopulmonary resuscitation. Initial ECG monitoring by paramedics showed ventricular fibrillation (Fig 1A⇓). The child was successfully resuscitated and rapidly stabilized after cardioversion, with excellent hemodynamics on arrival at the pediatric intensive care unit. Twelve-lead ECG changes were consistent with an acute inferior wall myocardial infarction (Fig 1B⇓). Two-dimensional echocardiography documented normal intracardiac anatomy with posterior left ventricular and septal wall dyskinesis associated with large (6- to 7-mm-diameter) aneurysms of the proximal left anterior descending (LAD) and left circumflex (LCx) coronary arteries (Fig 2⇓) highly suggestive of Kawasaki’s disease. On review, the parents described a self-limited febrile illness associated with rash and conjunctival injection approximately 6 weeks before the sudden collapse. Creatine kinase isoenzyme patterns confirmed myocardial injury, and radionuclide myocardial perfusion studies showed perfusion defects in the inferior and posterior left ventricle. Selective coronary angiography showed large aneurysms in the proximal and distal LAD and proximal LCx without obstruction (Fig 3⇓); an aneurysm in the proximal right coronary artery (RCA) was also identified, with poor antegrade filling of the distal RCA branches consistent with severe obstruction/thrombosis distal to the aneurysm. Retrograde filling of the distal RCA was appreciated via collaterals from the left coronary circulation. No surgical intervention was performed; the patient was maintained on long-term low-dose aspirin and dipyridamole, with rapid resolution of the segmental wall dyskinesis and perfusion defects by follow-up echocardiography and radionuclide scans. The LAD and LCx aneurysms have persisted by two-dimensional echocardiographic imaging.
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The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Lukes Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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