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Myocardial infarction due to thrombotic occlusion despite anticoagulation in Kawasaki disease - a case report
Diana van Stijn1, Nikki J Schoenmaker2, R Nils Planken3
1Department of Pediatric Immunology, Rheumatology and Infectious diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, location H8-253, Amsterdam, 1105 AZ, The Netherlands. d.vanstijn@amsterdamumc.nl.
Insights
Kawasaki disease (KD) can lead to giant coronary artery aneurysms (CAAs). Even with intensive anticoagulation, thrombus growth can cause myocardial ischemia, highlighting treatment challenges in pediatric vasculitis.
Area of Science:
- Pediatric Cardiology
- Vascular Inflammation
- Thrombosis Research
Background:
- Kawasaki disease (KD) is a pediatric vasculitis affecting coronary arteries.
- Acute inflammation can lead to coronary artery aneurysms (CAAs), increasing risks of thrombosis and myocardial ischemia.
- Timely anti-platelet and anticoagulation therapy is crucial for preventing severe cardiac events.
Observation:
- A 5-year-old girl with KD presented with giant CAAs and myocardial ischemia.
- Progressive thrombus growth occurred despite 21 months of intensive anticoagulation (aspirin, acenocoumarol, clopidogrel).
- Thrombus growth persisted after percutaneous coronary intervention (PCI) with thrombolysis and systemic thrombolysis.
Findings:
- Anticoagulation and thrombolysis proved insufficient for acute coronary syndrome in giant CAAs.
- Thrombus growth continued despite triple anticoagulation, likely due to low blood flow within the aneurysm.
- Coronary artery bypass grafting (CABG) was performed, but myocardial infarction was not prevented.
Implications:
- This case highlights the limitations of current anticoagulation and thrombolysis strategies for KD-associated giant CAAs.
- Effective management of thrombosis in pediatric patients with giant CAAs remains a significant clinical challenge.
- Further research into novel therapeutic approaches is warranted to prevent thrombotic occlusion and myocardial damage.
Background:
Kawasaki disease (KD) is a pediatric vasculitis. Mainly the coronary arteries become affected due to acute inflammation and formation of coronary artery aneurysms (CAAs) can occur. The larger the CAA, the higher the risk for clinical complications and major adverse cardiac events, as the blood flow changes to vortex or turbulent flow facilitating thrombosis. Such patients may develop life threatening thrombotic coronary artery occlusion and myocardial ischemiaunless anti-platelet and anti-coagulation therapy is timely initiated.
Case Presentation:
We present a unique case of a 5-year-old girl with KD associated giant CAAs suffering from myocardial ischemia due to acute progressive thrombus growth despite intensive anticoagulation treatment (acetylsalicylic acid, acenocoumarol and clopidogrel) after 21 months of onset of disease. Thrombus growth continued even after percutaneous coronary intervention (PCI) with thrombolytic treatment and subsequent systemic thrombolysis, finally causing lasting myocardial damage. Acute coronary artery bypass grafting (CABG) was performed, although technically challenging at this very young age. Whereas myocardial infarction was not prevented, follow-up fortunately showed favorable recovery of heart failure.
Conclusions:
Anticoagulation and thrombolysis may be insufficient for treatment of acute coronary syndrome in case of impending thrombotic occlusion of giant coronary aneurysms in KD. Our case demonstrates that a thrombus can still continue to grow despite triple anticoagulation therapy and well-tailored cardiovascular follow-up, which can be most likely attributed to the state of low blood flow inside the aneurysm.
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