Acute Myocardial Infarction in a Young Adult with

Coronary Artery Ectasia Presumably Caused by

Kawasaki Disease: The Role of Thrombosuction

Yu-Feng Chen,1 Tsochiang Ma,2 Ting-Chuan Chang,1 Mu-Hsin Chang,1 Chao-Hung Lai,1

Miin-Yaw Shyu3,* and Gwo-Ping Jong1,*

Direct percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) is now the standard

first-line therapy for all patients. However, few studies on PCI in young patients with AMI and Kawasaki disease

have been published. Herein, we report a case of AMI in a 26-year-old man with a history of Kawasaki disease.

Emergency coronary angiography showed a thrombotic occlusion of the ectatic left circumflex artery. PCI with

aspiration thrombectomy alone was performed successfully. Restenosis was not observed on coronary arteriography

at 6-month follow-up. Our report suggests that PCI with thrombosuction for young patients with AMI and Kawasaki

disease can be safe and effective.

Key Words: Acute myocardial infarction � Coronary artery ectasia � Kawasaki disease � Percutaneous

coronary intervention

INTRODUCTION

Kawasaki disease (KD) is an acute systemic inflam-

matory vasculitis involving medium-sized vessels with a

marked predilection for the coronary arteries.1,2 It occurs

predominantly in infants and young children. Although

normally self-limiting in childhood, KD can extend into

adulthood if left untreated. The etiology of KD is un-

known. Symptoms include acute vasculitis, skin rash, fe-

ver, skin desquamation, oral mucositis, conjunctivitis

and cervical lymphadenopathy.1 Patients with KD are at

increased risk for accelerated atherosclerosis and acute

myocardial infarction (AMI) in adolescence and adult-

hood.2

Direct percutaneous coronary intervention (PCI) for

acute myocardial infarction (AMI) is now the standard

first-line therapy for all patients. However, few studies

on PCI in young patients with AMI and Kawasaki dis-

ease have been published.3 Herein, we report a case of

AMI in a young adult with a history of Kawasaki dis-

ease. Emergency PCI with thrombosuction alone was

performed successfully.

CASE REPORT

A 26-year-old man in whom Kawasaki disease had

been diagnosed at the age of 18 months presented to our

emergency department because of sudden onset of chest

pain after breakfast. He denied any previous history of

hypertension. The patient did not have a history of smok-

ing and did not abuse alcohol. On physical examination,

his blood pressure was 154/104 mm Hg and his heart

165 Acta Cardiol Sin 2009;25:165�8

Acute Myocardial Infarction and Kawasaki DiseaseCase Report Acta Cardiol Sin 2009;25:165�8

Received: November 2, 2008 Accepted: May 26, 20091Division of Internal Cardiology, Armed Forces Taichung General

Hospital, and Central Taiwan University of Science and Technology;2Department of Health Service Management, China Medical Uni-

versity; 3Division of Internal Cardiology, Jen-Ai General Hospital,

Taichung, Taiwan.

Address correspondence and reprint requests to: Dr. Gwo-Ping Jong,

Department of Internal Medicine, Armed Forces Taichung General

Hospital, 348, Sec. 2, Chung-Shan Road, Taiping, Taichung, Taiwan.

Tel: 886-4-2393-8143; Fax: 886-4-2393-8143; E-mail: cgp8009@

yahoo.com.tw

*Dr. Miin-Yaw Shyu and Dr. Gwo-Ping Jong share equal contribution.

rate was 62 beats/min. Chest and heart examinations re-

vealed nothing unusual. A 12-lead electrocardiogram

(ECG) revealed ST depression in leads V4-V6 (Figure

1A). Furthermore, elevated cardiac enzymes (peak le-

vels: creatinine kinase/creatinine kinase myocardial

bound, 875/72.3 U/L) and elevated troponin-I level (2.5

ng/mL) were identified. The plasma levels of total cho-

lesterol, triglyceride, and low-density lipoprotein choles-

terol were 161, 121 and 88 mg/dL, respectively. Other

biochemistry and blood tests were within normal limits.

Echocardiogram showed normal left ventricular systolic

function. Non-ST segment elevation AMI was diag-

nosed. Emergency coronary angiography showed ectasia

of the proximal left anterior descending artery, and ec-

tasia, mild calcification and near-total thrombotic occlu-

sion of the proximal left circumflex artery (Figures 2A

and 2B). Direct PCI with thrombosuction was success-

fully performed (Figure 2C). The ECG returned to nor-

mal (Figure 1B), and chest pain subsided after direct

PCI. Although balloon angioplasty and stenting have

been well established as safe and effective therapies in

patients with AMI, thrombotic occlusion is commonly

present at the site of the culprit lesion, and distal throm-

bus embolization after PCI remains a serious problem.

We attempted only thrombus aspiration in this case be-

cause of typical intracoronary thrombus and the ab-

sence of significant stenosis of the site of the culprit le-

sion after resolution of thrombus. One hundred mg of

aspirin and 2.5 mg of warfarin daily were prescribed at

our outpatient clinic. Follow-up angiogram performed

6 months after the procedure revealed no restenosis

(Figure 2E).

Acta Cardiol Sin 2009;25:165�8 166

Yu-Feng Chen et al.

Figure 1. The 12-lead electrocardiograms (ECG) performed in the emergency department (A), and after percutaneous coronary angioplasty (B). At

the emergency department, the ECG showed ST depression in leads V4-V6. After percutaneous coronary angioplasty, the ECG returned to normal.

A

B

DISCUSSION

Hartnell et al.4 used the term coronary artery ectasia

(CAE) to define abnormal dilation of coronary segments

one and a half-fold or more of the adjacent normal seg-

ment. Coronary artery dilation may be localized or dif-

fuse with or without coronary artery stenosis. CAE is

observed in 1.2 to 4.9% of patients undergoing coronary

angiogram, and has been thought to be congenital or ac-

quired.5 The etiology and pathogenesis of this coronary

enlargement is not very well known. However, extensive

atherosclerotic changes and destruction of the media of

the coronary artery vessels seem to play a role in the

pathogenesis of CAE. Kruger et al.6 found that altered

coronary flow in CAE may induce unstable angina and

myocardial infarction.

167 Acta Cardiol Sin 2009;25:165�8

Acute Myocardial Infarction and Kawasaki Disease

Figure 2. (A) Left anterior cranial view of left coronary angiography,

showing an aneurysm of the proximal left anterior descending artery.

(B) Left anterior caudal view of left coronary angiography before

aspiration thrombectomy and percutaneous coronary angioplasty (PCI).

This image shows an aneurysm and mild calcification of the proximal

to middle left circumflex artery, and near-total thrombotic occlusion of

the middle left circumflex artery (arrowhead). (C) Left anterior caudal

view of left coronary angiography after aspiration thrombectomy and

PCI. Revascularization was successfully performed (arrowhead). (D)

Left anterior oblique view of the right coronary artery. (E) Six-month

follow-up left coronary angiography shows no restenosis of the left

circumflex artery (arrowhead).

A B

C D

E

Acute myocardial infarction in young adults is very

rare.3 The risk factors for coronary artery disease include

male gender, age above 40 years, current smoking, dia-

betes, obesity, hypertension, hyperlipidemia and family

history.7 In our patient, male gender was the only risk

factor. The most possible cause of AMI in our patient

was the coronary ectasia caused by Kawasaki disease.

Patients with a history of Kawasaki disease are at in-

creased risk for early-onset atherosclerosis, which in

turn puts them at risk for young-onset AMI.

Kawasaki disease is an acute systemic inflammatory

vasculitis that predominantly affects infants and young

children.1 Approximately 20% to 30% of untreated pa-

tients with KD develop coronary artery ectasia or an-

eurysms, which may lead to myocardial infarction, sud-

den death, or chronic artery insufficiency in adulthood.8

In Kawasaki disease, coronary ectasia or aneurysms de-

velop predominantly in the proximal segments and are

classified as either local or giant (> 8 mm in diameter).

The size of the ectasia or aneurysm is the most important

predictor of myocardial infarction.8 Giant ectasia or

aneurysms have a poor prognosis, do not regress and

usually result in ischemic heart disease. In our patient, it

is unknown when the ectasia developed. Since his KD

was never treated in childhood, and the disease was not

monitored, we suspect that the ectasia may have deve-

loped as a cardiovascular sequela of KD. Cardiovascu-

lar sequelae of Kawasaki disease may be an important

cause of ischemic heart disease in young adults; there-

fore, prophylactic antiplatelet therapy is indicated and

regular follow-up echocardiographic studies are recom-

mended.8 Giant or multiple coronary artery ectasia and

stenotic lesions are indications for coronary revascu-

larization.

Export aspiration catheter (EAC) is one of the com-

ponents of the GuardWire Plus system (PercuSurge,

Sunnyvale, CA). Several studies demonstrated its effi-

cacy during elective interventions, mainly on proximal

lesions of coronary arteries without an angled takeoff.9,10

Wang et al. reported its successful utilization in 9 pa-

tients undergoing primary PCI in native coronary le-

sions.9 The advantage of this technique is its ease of per-

formance without much time consumption in AMI pa-

tients. In our case, we could perform EAC with throm-

bosuction successfully without any complications.

Coronary artery sequelae of KD are known to be in-

volved in the development of adult coronary artery dis-

ease and may be an important cause of AMI in young

adults. Cardiologists should recognize this condition and

include the sequelae of KD in the differential diagnosis

of AMI in young adults. Based on our experience, direct

PCI for AMI in patients with Kawasaki disease can be

safe and effective.

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