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Young man presenting with out-of-hospital cardiac arrest
  1. Hans David Huang,
  2. William L Lombardi,
  3. Zachary Louis Steinberg
  1. Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Hans David Huang, Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA 98195, USA; huangh27{at}uw.edu

Abstract

Clinical introduction A man in his early 30s with remote history of a febrile rash as a toddler presented to the emergency room following an out-of-hospital cardiac arrest while riding his bicycle. He received bystander cardiopulmonary resuscitation and one shock from an automatic external defibrillator, successfully restoring sinus rhythm. On arrival, he was haemodynamically stable without ECG evidence of ST segment changes to suggest active ischaemia, and an initial troponin I was mildly elevated at 0.10 ng/mL (normal <0.04 ng/mL). A CT angiogram (CTA) was obtained showing a normal-appearing aorta and no abnormal extracardiac findings. Urgent coronary angiography was performed; images are shown in figure 1A–C. Echocardiogram revealed a mildly reduced left ventricular ejection fraction (45%) with a hypokinetic inferior wall.

Figure 1

(A) Right coronary artery angiogram in the left anterior oblique cranial projection. (B) Left coronary artery angiogram in the right anterior oblique caudal projection. (C) Left coronary artery angiogram in the right anterior oblique cranial projection. CAUD, caudal; CRAN, cranial; LAO, left anterior oblique; RAO, right anterior oblique.

Question What is the next best step in the management of this patient at this time?

  1. Complete revascularisation via percutaneous coronary intervention (PCI).

  2. Referral for coronary artery bypass surgery (CABG).

  3. Initiation of high-dose steroids.

  4. Initiation of dual-antiplatelet therapy without planned revascularisation.

  • cardiac catheterization and angiography
  • interventional cardiology and endovascular procedures
  • cardiac arrest
  • coronary artery disease
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Answer: B

Figure 1A shows a proximally aneurysmal dominant right coronary artery with sequential high-grade stenoses throughout the vessel. The posterior descending artery is chronically occluded at its ostium and fills via left coronary artery collaterals (figure 1B,C). Figure 1B,C shows a large left main coronary aneurysm extending into the proximal left anterior descending and left circumflex (LCX) coronary arteries. High-grade stenoses are present within the proximal LCX and first obtuse marginal branch. Given the history of febrile rash, appearance of the large coronary aneurysms on angiography and absence of additional vascular abnormalities on CTA, this patient’s presentation is consistent with a history of Kawasaki disease (KD) complicated by giant coronary aneurysms (GCAs). In older children and adults with obstructive coronary artery disease within GCAs as a result of KD, observational studies have demonstrated long-term internal mammary graft patency following CABG.1 Comparatively little is known about the success rates of PCI and its long-term durability in this patient population. Therefore, current recommendations support CABG with bilateral internal thoracic arterial grafts as the primary mode of revascularisation in adults with multivessel coronary artery disease as a result of KD.2 Answer A is incorrect because this patient is haemodynamically stable, without evidence of acute ischaemia. Therefore, CABG should be considered as the primary revascularisation strategy. Answer C is incorrect as the vasculitis associated with KD manifests in childhood and resolves within a matter of weeks to months. Treatment with steroids is, therefore, not warranted at this time. Given the finding of high-grade coronary artery stenoses in the setting of a non-perfusing ventricular arrhythmia, coronary artery revascularisation should be pursued; therefore, answer D is incorrect.

References

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Footnotes

  • Contributors All authors participated in the writing and editing of the manuscript. All authors are responsible for the overall content of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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