- Email: [email protected]
Subcostal 2-dimensional echocardiographic imaging of peripheral left coronary artery aneurysms in Kawasaki disease
Subcostal 2-Dimensional EchocardiographicImaging of Peripheral Left Coronary Artery Aneurysms in Kawasaki Disease TOSHIKI MAEDA, MD, HITOSHI YOSHIDA, MD, TAKASHI FUNABASHI, MD, SHIGEKAZU NAKAYA,
MD, SHOJI TAKABATAKE,
MD, TAKASHI OHNO, MD,
and NOBORU TANIGUCHI, MD
Our previous study provided a new P-dimensional echocardiographic technique to detect peripheral right coronary artery aneurysms in Kawasaki disease, with use of the subcostal approach. An additional study was performed to detect peripheral lefl coronary artery aneurysms. Because the lefl anterior descending artery runs along the anterior interventricular sulcus and the left circumflex artery along the mitral valve ring, these regions were searched for coronary aneurysms by use of the subcostal imaging approach. Among 143 patients
with Kawasaki disease, 44 lefl coronary aneurysms were visualized in 22 patients. Three aneurysms at the origin of the obtuse marginal artery and 1 in the further peripheral site of the left circumflex artery were observed in 3 patients. Two aneurysms at the origin of the second diagonal branch of the peripheral left anterior descending artery were detected. These echocardiographic studies were done prospectively, and their features coincided well in size, shape, and anatomic location with confirmatory angiographic appearances.
Recognition of coronary aneurysms by noninvasive methods is useful in following up patients with Kawasaki disease because coronary aneurysm is an ominous complication that carries a risk of sudden death.l-s Two-dimensional (2-D) echocardiography can be used to visualize coronary aneurysms using the parasternal horizontal approach at the level of the aorta.1°-13 However, this approach visualizes only limited areas of the proximal segments of the coronary arteries. In our previous study, we described a technique for detecting peripheral coronary aneurysms of the right coronary artery.14 In the present study, we describe a technique for detecting peripheral coronary aneurysms of the left coronary artery from the ostium to terminal sites in both the left anterior descending (LAD) and left circumflex (LC) arteries, using the subcostal approach.
basis of guidelines prepared by the Japanese Research Committee in 1978. Coronary angiography was performed in 34 patients with Kawasaki disease: 31 patients were suspected of having coronary aneurysms on 2-D echocardiography. The other 3 patients had no positive findings on 2-D echocardiography but were severely affected on the basis of clinical features and laboratory data. We performed this study using a real-time mechanical sector instrument (Aloka SSD 1000 with ASU 25 hand scanner and USM 6B amplifier). The scanner probe, which contained a 3 MHz transducer focused at 7.5 cm, was mechanically driven through a variable angle (30” to 80”) at a rate of 30 frames/s, yielding a line density of approximately 110 lines/ frame. Two-dimensional echocardiographic images were observed in real time during the examinations. The images, which were displayed as phase-selected single frames, were photographed directly from the oscilloscope screen with a Polaroid@ camera, and real-time images were recorded with a 16 mm cinecamera and analyzed subsequently in real-time, slow motion, and single format. Anatomically, the left main coronary artery originates from the left coronary sinus and passes between the pulmonary trunk in the front and left atria1 appendage behind. A short distance from its origin, usually a few millimeters in infants and children, it divides into LAD and LC arteries. The LAD artery passes downward over the anterior surface of the heart along the full length of the anterior interventricular sulcus and onto the inferior surface. The LC artery departs at an acute angle from the left main coronary artery to run posteriorly along the atrioventricular groove, toward the crux cordis.
Methods Two-dimensional echocardiograms were recorded in 143 patients with Kawasaki disease (86 male and 57 female), aged 2 months to 8 years, whose conditions were assessed on the From the Department of Pediatrics, School of Medicine, Kanazawa University, Kanazawa, Japan. Manuscript received January 13, 1983; revised manuscript received March 31, 1983, accepted April 4, 1983. Address for reprints: Toshiki Maeda, MD, Department of Pediatrics, School of Medicine, Kanazawa University, Takaramachi 13-1, Kanazawa 920, Japan.
July 1983
Pl
Pl
LC
FIGURE 1. Schematic drawings of the subcostal view for imaging coronary aneurysms in segments 11 and 13 of the left circumflex artery. Left, the position of sector Pl, showing a view of the 4 chambers. The left circumflex aneurysms can be detected at the left side of the mitral valve. I = inferior; L = left; LA =z left atrium: LAD = left anterior descending artery; LC = left circumflex artery; LV = left ventricle; R = right; RA = right atrium; RV = right ventricle; S = superior; 11 and 13 = segments 11 and 13.
Throughout this course, the LC artery encircles the mitral valve ring.15-17 The subcostal approach that we developed for imaging peripheral coronary aneurysms of the left coronary artery consists of 2 parts. The first is a subcostal frontal approach (Fig. 1). The scanner probe was initially oriented so that the sector beam was directed through the heart on a plane parallel to a line between the patient’s shoulders, allowing simultaneous visualization of the 4 chambers (sector P1).18s1gIn the section, the LC artery runs along the left side of the mitral valve ring. The scan plane was angled more posteriorly for imaging the peripheral site osfthe LC artery, that is, segment
FIGURE 2. Schematic drawings of the subcostal views for imaging coronary aneurysms in segments 6, 7, and 6 of the left anterior descending artery and segments 11 and 13 of the left circumflex artery. The top IeH panel shows the position of sectors P2, P3, P4, and P5. Scanning from P2 to P4, coronary aneurysms of the left circumflex artery can be detected. Scanning from P3 to P5, coronary aneurysms of the left anterior descending artery can be detected. A = anterior; I = inferior; LA = left atrium; LAD = left anterior descending artery; LC = left circumflex artery; LM = left main coronary artery; LV = left ventricle; mv = mitral valve; P - posterior; PPM = posterior papillary muscle: RV = right ventricle; S = superior; 56, 7, 6, 11, and 13 = segments 5, 6. 7, 6, 11 and 13.
THE AMERICAN JOURNAL OF CARDIOLOGY Volume 52
49
13 (segment classification according to American Heart Committee Reportso). The second part is a subcostal sagittal approach (Fig. 2). The section was first positioned roughly parallel to a plane cutting both the long axes of the sternum and spinal column, allowing simultaneous visualization of the right ventricular outflow tract, pulmonary valves, interventricular septum, mitral valve, and left atrium (sector P2).21 Next, the sector plane was angled to the left as plane P3 in Figure 2. In sectors P2 and P3, the peripheral LC artery (segment 13) runs along the inferoposterior side of the mitral valve ring. By scanning sectors P2 and P3, the inferoposterior area of the mitral valve ring was examined for coronary aneurysms. Then the sector plane was tilted more to the left, with the left atrium just disappearing, so that the left ventricular cavity was imaged in the short axis (sector P4). In this sector, the LC artery can be seen running along the supraposterior side of the left ventricle around the mitral valve ring, and the LAD artery runs along the superior side of the interventricular septum. The sector plane was tilted more to the cardiac apex (sector P5) so that the LAD runs along the superior side of the interventricular septum. Technical considerations involved in recording coronary aneurysms must be done with this subcostal sagittal approach. Particularly in sectors P2 and P3, the interventricular septum must be differentiated from the tricuspid valve. The tricuspid valve will be imaged slightly angled to the right and can be distinguished by its shape and motion. Also, it would be very helpful to use a peripheral vein contrast echo that distinguishes the tricuspid valve and interventricular septum, because the tricuspid valve would be filled with contrast echoes. The mitral valve, which is posterior to the interventricular septum, would be differentiated from the other structures of the heart by confirming the interventricular septum.
Results Among
143 patients
with
Kawasaki
disease,
left
coronary aneurysms were visualized in 22 patients by 2-D echocardiography, including the proximal segments. Concerning the peripheral left coronary artery,
P4
P5
50
LEFT CORONARY ARTERY ANEURYSMS IN KAWASAKI DISEASE
6 aneurysms (3 in the LC artery at the origin of the obtuse marginal artery, 1 in segment 13, and 2 in the LAD artery at the origin of the second diagonal branch) were detected with the subcostal approach. The echocardiographic findings of these 6 peripheral left coronary aneurysms almost coincided in size, shape, and ana-
g
21
aneurysms
lrysms
PlGlJRE 3. The number of left coronary aneuysms in each location by angiography. Forty-four left coronary aneurysms were shown in 22 patients with Kawasaki disease. 01 = first diagonal branch; 02 = second diagonal branch: LAD = left anterior descending artery: LC = left circumflex artery; OM = obtuse marginal artery: PD = posterior descending branch; PL = posterolateral branch.
tomic position with angiographic features found later. However, coronary angiography, performed in all 34 patients suspected of having right or left coronary aneurysms, or both, by 2-D echocardiography and clinical findings, showed 2 aneurysms in segment 13 in 1 patient (Fig. 3). These 2 aneurysms were located at the origins of the posterolateral branch and the posterior descending branch and at first were regarded as 1 aneurysm in segment 13 by 2-D echocardography. Figure 4A, a 2-D echocardiogram in sector Pl from a patient with Kawasaki disease, shows an abnormal oval echo-free space, approximately 6 by 5 mm, at the left side of the mitral valve. This space was also imaged at the supraposterior side of the left ventricle around the mitral valve ring in sector P4 (Fig. 4B). The coronary aniogram (Fig. 4C) shows a coronary aneurysm at the origin of the obtuse marginal artery. Figure 5A, a 2-D echocardiogram in sector P3 from a patient with Kawasaki disease, shows 3 abnormal echo-free spaces. One of these, approximately 4 by 4 mm, is seen at the inferior side of the mitral valve, adjacent to the liver. The coronary angiogram shows it to be a peripheral LC aneurysm in segment 13 (Fig. 5B). Another echo-free space, which the coronary angiogram (Fig. 5B) disclosed to be an aneurysm of the proximal LC artery, is visualized at the superior side of the mitral valve. The other echo-free space, which the coronary angiogram disclosed to be an aneurysm of the proximal
A
FIGURE 4. Twodimensional ecftocardtograms and coronary angiogram from a l-year-old boy with Kawasaki disease. A, sector Pl showing an abnormal echo-free space (arrow) at the left side of the mitral vafve. B, sector P4 showing the same coronary aneurysm as in A. C, angiogram showing 2 coronary aneurysms (30’ right anterior oblique view). A coronary aneurysm (large arrow) at the origin of the obtuse marginal artery (small arrow) corresponds to echo-free spaces in A and B. A = anterior: I = inferior; L = left; LA = left atrium; LC = left circumflex artery: LV = left ventricle; mv = mitral valve; P = posterior; R = right; RA = right atrium; RV = right ventricle; S = superior.
July 1983
LAD artery, is visualized at the superior side of the interventricular septum. Figure 6A, a 2-D echocardiogram in sector P5 from a patient with Kawasaki disease, shows an oval echofree space, approximately 3 by 2 mm, at the superior side of the interventricular septum. The coronary angiogram (Fig. 6B) shows a coronary aneurysm of the portion where the LAD artery branches off the second diagonal branch.
THE AMERICAN JOURNAL OF CARDIOLOGY Volume 52
51
wasaki disease in order to determine the prognosis, because stenotic and obstructive changes of the coronary artery cannot be easily visualized with 2-D echocardiography. It has been reported that the parasternal horizontal approach at the level of the aorta by 2-D echocardiography can visualize the proximal segments of the coronary artery.lO-la However, this approach can image the coronary artery for only a few millimeters from the ostium. In a previous study, we described a new method of searching for peripheral right coronary aneurysms.14 In the present study, we initiated a method of detecting peripheral left coronary aneurysm in both the LAD and LC arteries by using the subcostal appreach. This method allowed the visualization of peripheral coronary aneurysms that could not be detected
Discussion Stenosis and obstructio:n of the coronary artery with Kawasaki disease, which carry a risk of sudden death, commonly occur in the front and rear of aneurysms. It is therefore important to recognize aneurysms in Ka-
6
I 1
.
P&A
FIGURE 5. Two-dimensional echocardiogram and coronary angiogram from a P-year-old boy with Kawasaki disease. A, sector P3 showing 3 abnormal echo-free spaces. One space is seen at the inferior side of the mitral valve (upper small arrow). Another is seen at the superior side of the mitral valve (lower small arrow). The other space is seen at the superior side of the interventricular septum (large arrow). B, angiogram showing several aneurysms of the left coronary artery (30’ right anterior oblique view). The large arrow corresponds to the large arrow in A. The upper small arrow corresponds to the lower small arrow in A. The lower small arrow corresponds to the upper small arrow in A. A = anterior: I = inferior; ivs = interventricular septum; LA = left atrium; LAD = left anterior descending artery; LC = left circumflex artery; LV = left ventricle; mv = mitral valve: P = posterior; periph. LC = perilpheral left circumflex artery; RV = right ventricle; S = superior.
I P-
-f-
A
FIGURE 6. Two-dimensional echocardiogram and coronary angiogram from an &month-old boy with Kawasaki disease. A, sector P5 showing an oval echo-free space at the superior side of the interventricular septum. B, angiogram revealing 4 coronary aneurysms. A coronary aneurysm (arrow) of the portion where the left anterior descending artery branches off the second diagonal branch corresponds to an echofree space in A. A = anterior; I = inferior; ivs = interventricular septum; LAD = left anterior descending artery; LV = left ventricle; P = posterior; RAO = right anterior oblique; RV = right ventricle; S = superior.
52
LEFT CORONARY ARTERY ANElJRYSMs IN KAWASAKI DISEASE
with the parasternal horizontal approach. The images of the peripheral left coronary aneurysms, although not perfect, coincided well in size, shape, and anatomic position with the angiographic appearances later confirmed. With regard to the proximal segments, the parasternal horizontal approach is better than the subcostal approach because the former can detect coronary arteries on a long axis. In this study, why the peripheral coronary aneurysms were not detected in the parasternal or apical approach without large aneurysms is an important question. The peripheral LAD aneurysms could be visualized using the parasternal short-axis view of the left ventricle at the level of the mitral valve papillary muscles. The parasternal short-axis view of the left ventricle at the level of the mitral valve ring and a parasternal or apical 4chamber view should be useful for visualizing the peripheral portion of the LC artery. It is probable that we were not able to visualize peripheral coronary artery aneurysms in the parasternal views because we used a 3 MHz transducer focused at 7.5 cm. If we had used a transducer with a shorter focus, we might have been able to see these aneurysms from the precordial views. Although the peripheral coronary artery, in normal infants and children, could not be visualized with the subcostal approach, we were able to image the dilatation of the peripheral LC artery (approximately 2 by 2 mm) because of Kawasaki disease in sectors P2 and P3. This technique may be limited in distinguishing small coronary aneurysms from the normal coronary artery because the peripheral segments of the left coronary artery are cut in slices. Therefore we had to obtain confirmation by angiography in all patients whose peripheral left coronary arterial echo-free spaces were visualized by subcostal approach. Because patients who underwent angiography were selected largely on the basis of their echocardiographic and clinical findings, we were unable to make any statements about false-negative results in the detection of peripheral coronary artery aneurysms. Further comparative studies with both echocardiography and coronary angiography may be required in many cases. The parasternal horizontal approach is a good technique as it can image even the normal coronary artery on a long axis, but it can image only limited areas of proximal segments. Our previous study provided a technique for detecting peripheral right coronary aneurysms with use of the subcostal approach.14 In the
present study, we describe a new technique for detecting peripheral left coronary aneurysms in both LAD and LC arteries. By combining these 3 techniques, almost all coronary aneurysms, located in either the proximal or the distal artery, can be visualized with 2-D echocardiography.
References 1. Kawasakl T, Koaaki F, Okawa S, Shigematsu I, Yanagawa H. A new infantile acute mucocutaneous lymph node syndrome (MLNS) prevailing in Japan. Pediatrics 1974:54:271-278. 2. Takao A, Kusakawa S, Hamada I, Ando M, Asal T. Cardiovascular lesions of mucocutanaous lymph node syndrome (abstr). Circulation 1974;5O:Suppl 8l:lll-39. 3. Yanagtaawa Y, Kobayaabl N. Malsuya S. Mvocardial infarction due to coron-&y thromboarte?itis following acute febrile mucocutaneous lymph node syndrome (MLNS) in an infant. Pediatrics 1974;54:277-281. 4. Kate H, Kolke S, Yamamato M, Ho Y, Tam E. Coronary anauysm in infants and young children wtth acute febrile mucocutaneous lymph node syndrcma. Pediatrics 1975;88:892-898. 5. Dnouchl 2, Tomlzawa N, Goto M, Nakala K, Fukuda Y. Cardiac involvemant and prognosis in acute febrile mucfxxrtanaous lymph node syndrome. Chest.l975;88:297-301. 8. Radford DJ, Sondeheimer HM, Williams GJ, Fowler RS. Mucocutaneous lymph node syndrome with coronary artery aneurysm. Am J Ois Child 1978;130:598-598. 7. Kttamura S, Kawaahlma Y, Kawachl K, FuJIno M, Kozuka T, Fujtta T, Manaba H. Lefl ventricular function in patients with coronary arteritis due to acute febrile mucocutanaous lymph node synrkome or related diseases. Am J Cardiol 1977;40:158-184. 6. Kegel SM, Doraey TJ, Rowen M, Taylor WF. Cardiac death in mucocutaneous lymph noda syndrome. Am J Cardiol 1977;40:282-288. 9. Fujlwara H, Hamashima Y. Pathology of the heart in Kawasaki disease. Pediatrics 1978;81:100-107. 10. Matauo H, Mataumoto M, Hamanaka Y. Direct vtsualizattt of aneurysms of coronary artery in acute febrile mucocutaneous lymph node syndrome (MCLS). Electronic sector two-dimensional echocardtNgraphy (abstr). Jpn J Mad Ultrasonic 1977;31:139-140. 11. Yoahlkawa J, Yanagthara K, Dwakl T, Kato H. Takagt Y, Dkumachl F, Fukuya T, Tomlta Y, Baba K. Crass-sectional echocan%iographicdiagnosis of coronary artery aneurysms in patients with the mucocutaneous lymph node syndrome. Circulation 1979;59:133-139. 12. Hlralabi S, Yashlro K, Kuaano S. Noninvasive visualization of coronary arterial aneurysm in infants and young children with muccc&neous lymph node syndrorim with twodimensiorial echocardiography. Am J drdiol 1979:43:1225-1233. 13. Yo+ida H, Funabaahl T, Nakaya S,. Tanlguchl N..Mucocutaneous lymph nooa syncrcme. A cross-sectronar achocardiographic diagnosis of coronary aneurysms. Am J Ois Child 1979:133:1244-1247. 14. Yoshida H, Maeda T, FunabasMT, Nakaya S, Takabalake S, Tan uchl IR. Subcostal two-dimensional echocardiograph,ic imaging of perrp %e ral r9rs:t coronary artery rn Kawasakr drsease. Crrculatron 1982;85:95615. k&Alpine WA. Heart and Coronary Arteries. Berlin: Springer-Verlag. 1975133-209. 18. Watmsley R, Watson Ht Kirklln JW. Clinical Anatomy of the Heart. Edinburgh: Churchill and Livrngstone, 1978:199-216. 17. Gensinl GG. Coronary arteriography. In: Brawnwald E. ed. Heart Disease. A Textbook of Cardiovascular Medicine. Philadelphia: WB Saunders, 1980:308-362. 18. Lange LW, Sahn DJ, Allen HD, Goldberg SJ. Subxiphoid cross-sectional echocardiography in infants and children with congenital heart disease. Circulation 1979;59:513-524. 19. Blerman FZ, Wllllatns RG. Subxiphoid two-dimensional imaging _ _ of the interatrial septum in infants and neonates with congenital heart disease. Circulation 1979:60:80-90. 20. American Heart Association Committee Report. A reporting system on patients evaluated for coronary artery disease. Circulation 1975; 51 [Suppl]:7-40. 21. Goldberg SJ, Allen HD, Sahn DJ. Pulmonary stenosis. pediatric and Adolescent Echocardiography. 2nd ad. Chicago. London: Year Book Medical. 1980:204-212.
MD, SHOJI TAKABATAKE,
MD, TAKASHI OHNO, MD,
and NOBORU TANIGUCHI, MD
Our previous study provided a new P-dimensional echocardiographic technique to detect peripheral right coronary artery aneurysms in Kawasaki disease, with use of the subcostal approach. An additional study was performed to detect peripheral lefl coronary artery aneurysms. Because the lefl anterior descending artery runs along the anterior interventricular sulcus and the left circumflex artery along the mitral valve ring, these regions were searched for coronary aneurysms by use of the subcostal imaging approach. Among 143 patients
with Kawasaki disease, 44 lefl coronary aneurysms were visualized in 22 patients. Three aneurysms at the origin of the obtuse marginal artery and 1 in the further peripheral site of the left circumflex artery were observed in 3 patients. Two aneurysms at the origin of the second diagonal branch of the peripheral left anterior descending artery were detected. These echocardiographic studies were done prospectively, and their features coincided well in size, shape, and anatomic location with confirmatory angiographic appearances.
Recognition of coronary aneurysms by noninvasive methods is useful in following up patients with Kawasaki disease because coronary aneurysm is an ominous complication that carries a risk of sudden death.l-s Two-dimensional (2-D) echocardiography can be used to visualize coronary aneurysms using the parasternal horizontal approach at the level of the aorta.1°-13 However, this approach visualizes only limited areas of the proximal segments of the coronary arteries. In our previous study, we described a technique for detecting peripheral coronary aneurysms of the right coronary artery.14 In the present study, we describe a technique for detecting peripheral coronary aneurysms of the left coronary artery from the ostium to terminal sites in both the left anterior descending (LAD) and left circumflex (LC) arteries, using the subcostal approach.
basis of guidelines prepared by the Japanese Research Committee in 1978. Coronary angiography was performed in 34 patients with Kawasaki disease: 31 patients were suspected of having coronary aneurysms on 2-D echocardiography. The other 3 patients had no positive findings on 2-D echocardiography but were severely affected on the basis of clinical features and laboratory data. We performed this study using a real-time mechanical sector instrument (Aloka SSD 1000 with ASU 25 hand scanner and USM 6B amplifier). The scanner probe, which contained a 3 MHz transducer focused at 7.5 cm, was mechanically driven through a variable angle (30” to 80”) at a rate of 30 frames/s, yielding a line density of approximately 110 lines/ frame. Two-dimensional echocardiographic images were observed in real time during the examinations. The images, which were displayed as phase-selected single frames, were photographed directly from the oscilloscope screen with a Polaroid@ camera, and real-time images were recorded with a 16 mm cinecamera and analyzed subsequently in real-time, slow motion, and single format. Anatomically, the left main coronary artery originates from the left coronary sinus and passes between the pulmonary trunk in the front and left atria1 appendage behind. A short distance from its origin, usually a few millimeters in infants and children, it divides into LAD and LC arteries. The LAD artery passes downward over the anterior surface of the heart along the full length of the anterior interventricular sulcus and onto the inferior surface. The LC artery departs at an acute angle from the left main coronary artery to run posteriorly along the atrioventricular groove, toward the crux cordis.
Methods Two-dimensional echocardiograms were recorded in 143 patients with Kawasaki disease (86 male and 57 female), aged 2 months to 8 years, whose conditions were assessed on the From the Department of Pediatrics, School of Medicine, Kanazawa University, Kanazawa, Japan. Manuscript received January 13, 1983; revised manuscript received March 31, 1983, accepted April 4, 1983. Address for reprints: Toshiki Maeda, MD, Department of Pediatrics, School of Medicine, Kanazawa University, Takaramachi 13-1, Kanazawa 920, Japan.
July 1983
Pl
Pl
LC
FIGURE 1. Schematic drawings of the subcostal view for imaging coronary aneurysms in segments 11 and 13 of the left circumflex artery. Left, the position of sector Pl, showing a view of the 4 chambers. The left circumflex aneurysms can be detected at the left side of the mitral valve. I = inferior; L = left; LA =z left atrium: LAD = left anterior descending artery; LC = left circumflex artery; LV = left ventricle; R = right; RA = right atrium; RV = right ventricle; S = superior; 11 and 13 = segments 11 and 13.
Throughout this course, the LC artery encircles the mitral valve ring.15-17 The subcostal approach that we developed for imaging peripheral coronary aneurysms of the left coronary artery consists of 2 parts. The first is a subcostal frontal approach (Fig. 1). The scanner probe was initially oriented so that the sector beam was directed through the heart on a plane parallel to a line between the patient’s shoulders, allowing simultaneous visualization of the 4 chambers (sector P1).18s1gIn the section, the LC artery runs along the left side of the mitral valve ring. The scan plane was angled more posteriorly for imaging the peripheral site osfthe LC artery, that is, segment
FIGURE 2. Schematic drawings of the subcostal views for imaging coronary aneurysms in segments 6, 7, and 6 of the left anterior descending artery and segments 11 and 13 of the left circumflex artery. The top IeH panel shows the position of sectors P2, P3, P4, and P5. Scanning from P2 to P4, coronary aneurysms of the left circumflex artery can be detected. Scanning from P3 to P5, coronary aneurysms of the left anterior descending artery can be detected. A = anterior; I = inferior; LA = left atrium; LAD = left anterior descending artery; LC = left circumflex artery; LM = left main coronary artery; LV = left ventricle; mv = mitral valve; P - posterior; PPM = posterior papillary muscle: RV = right ventricle; S = superior; 56, 7, 6, 11, and 13 = segments 5, 6. 7, 6, 11 and 13.
THE AMERICAN JOURNAL OF CARDIOLOGY Volume 52
49
13 (segment classification according to American Heart Committee Reportso). The second part is a subcostal sagittal approach (Fig. 2). The section was first positioned roughly parallel to a plane cutting both the long axes of the sternum and spinal column, allowing simultaneous visualization of the right ventricular outflow tract, pulmonary valves, interventricular septum, mitral valve, and left atrium (sector P2).21 Next, the sector plane was angled to the left as plane P3 in Figure 2. In sectors P2 and P3, the peripheral LC artery (segment 13) runs along the inferoposterior side of the mitral valve ring. By scanning sectors P2 and P3, the inferoposterior area of the mitral valve ring was examined for coronary aneurysms. Then the sector plane was tilted more to the left, with the left atrium just disappearing, so that the left ventricular cavity was imaged in the short axis (sector P4). In this sector, the LC artery can be seen running along the supraposterior side of the left ventricle around the mitral valve ring, and the LAD artery runs along the superior side of the interventricular septum. The sector plane was tilted more to the cardiac apex (sector P5) so that the LAD runs along the superior side of the interventricular septum. Technical considerations involved in recording coronary aneurysms must be done with this subcostal sagittal approach. Particularly in sectors P2 and P3, the interventricular septum must be differentiated from the tricuspid valve. The tricuspid valve will be imaged slightly angled to the right and can be distinguished by its shape and motion. Also, it would be very helpful to use a peripheral vein contrast echo that distinguishes the tricuspid valve and interventricular septum, because the tricuspid valve would be filled with contrast echoes. The mitral valve, which is posterior to the interventricular septum, would be differentiated from the other structures of the heart by confirming the interventricular septum.
Results Among
143 patients
with
Kawasaki
disease,
left
coronary aneurysms were visualized in 22 patients by 2-D echocardiography, including the proximal segments. Concerning the peripheral left coronary artery,
P4
P5
50
LEFT CORONARY ARTERY ANEURYSMS IN KAWASAKI DISEASE
6 aneurysms (3 in the LC artery at the origin of the obtuse marginal artery, 1 in segment 13, and 2 in the LAD artery at the origin of the second diagonal branch) were detected with the subcostal approach. The echocardiographic findings of these 6 peripheral left coronary aneurysms almost coincided in size, shape, and ana-
g
21
aneurysms
lrysms
PlGlJRE 3. The number of left coronary aneuysms in each location by angiography. Forty-four left coronary aneurysms were shown in 22 patients with Kawasaki disease. 01 = first diagonal branch; 02 = second diagonal branch: LAD = left anterior descending artery: LC = left circumflex artery; OM = obtuse marginal artery: PD = posterior descending branch; PL = posterolateral branch.
tomic position with angiographic features found later. However, coronary angiography, performed in all 34 patients suspected of having right or left coronary aneurysms, or both, by 2-D echocardiography and clinical findings, showed 2 aneurysms in segment 13 in 1 patient (Fig. 3). These 2 aneurysms were located at the origins of the posterolateral branch and the posterior descending branch and at first were regarded as 1 aneurysm in segment 13 by 2-D echocardography. Figure 4A, a 2-D echocardiogram in sector Pl from a patient with Kawasaki disease, shows an abnormal oval echo-free space, approximately 6 by 5 mm, at the left side of the mitral valve. This space was also imaged at the supraposterior side of the left ventricle around the mitral valve ring in sector P4 (Fig. 4B). The coronary aniogram (Fig. 4C) shows a coronary aneurysm at the origin of the obtuse marginal artery. Figure 5A, a 2-D echocardiogram in sector P3 from a patient with Kawasaki disease, shows 3 abnormal echo-free spaces. One of these, approximately 4 by 4 mm, is seen at the inferior side of the mitral valve, adjacent to the liver. The coronary angiogram shows it to be a peripheral LC aneurysm in segment 13 (Fig. 5B). Another echo-free space, which the coronary angiogram (Fig. 5B) disclosed to be an aneurysm of the proximal LC artery, is visualized at the superior side of the mitral valve. The other echo-free space, which the coronary angiogram disclosed to be an aneurysm of the proximal
A
FIGURE 4. Twodimensional ecftocardtograms and coronary angiogram from a l-year-old boy with Kawasaki disease. A, sector Pl showing an abnormal echo-free space (arrow) at the left side of the mitral vafve. B, sector P4 showing the same coronary aneurysm as in A. C, angiogram showing 2 coronary aneurysms (30’ right anterior oblique view). A coronary aneurysm (large arrow) at the origin of the obtuse marginal artery (small arrow) corresponds to echo-free spaces in A and B. A = anterior: I = inferior; L = left; LA = left atrium; LC = left circumflex artery: LV = left ventricle; mv = mitral valve; P = posterior; R = right; RA = right atrium; RV = right ventricle; S = superior.
July 1983
LAD artery, is visualized at the superior side of the interventricular septum. Figure 6A, a 2-D echocardiogram in sector P5 from a patient with Kawasaki disease, shows an oval echofree space, approximately 3 by 2 mm, at the superior side of the interventricular septum. The coronary angiogram (Fig. 6B) shows a coronary aneurysm of the portion where the LAD artery branches off the second diagonal branch.
THE AMERICAN JOURNAL OF CARDIOLOGY Volume 52
51
wasaki disease in order to determine the prognosis, because stenotic and obstructive changes of the coronary artery cannot be easily visualized with 2-D echocardiography. It has been reported that the parasternal horizontal approach at the level of the aorta by 2-D echocardiography can visualize the proximal segments of the coronary artery.lO-la However, this approach can image the coronary artery for only a few millimeters from the ostium. In a previous study, we described a new method of searching for peripheral right coronary aneurysms.14 In the present study, we initiated a method of detecting peripheral left coronary aneurysm in both the LAD and LC arteries by using the subcostal appreach. This method allowed the visualization of peripheral coronary aneurysms that could not be detected
Discussion Stenosis and obstructio:n of the coronary artery with Kawasaki disease, which carry a risk of sudden death, commonly occur in the front and rear of aneurysms. It is therefore important to recognize aneurysms in Ka-
6
I 1
.
P&A
FIGURE 5. Two-dimensional echocardiogram and coronary angiogram from a P-year-old boy with Kawasaki disease. A, sector P3 showing 3 abnormal echo-free spaces. One space is seen at the inferior side of the mitral valve (upper small arrow). Another is seen at the superior side of the mitral valve (lower small arrow). The other space is seen at the superior side of the interventricular septum (large arrow). B, angiogram showing several aneurysms of the left coronary artery (30’ right anterior oblique view). The large arrow corresponds to the large arrow in A. The upper small arrow corresponds to the lower small arrow in A. The lower small arrow corresponds to the upper small arrow in A. A = anterior: I = inferior; ivs = interventricular septum; LA = left atrium; LAD = left anterior descending artery; LC = left circumflex artery; LV = left ventricle; mv = mitral valve: P = posterior; periph. LC = perilpheral left circumflex artery; RV = right ventricle; S = superior.
I P-
-f-
A
FIGURE 6. Two-dimensional echocardiogram and coronary angiogram from an &month-old boy with Kawasaki disease. A, sector P5 showing an oval echo-free space at the superior side of the interventricular septum. B, angiogram revealing 4 coronary aneurysms. A coronary aneurysm (arrow) of the portion where the left anterior descending artery branches off the second diagonal branch corresponds to an echofree space in A. A = anterior; I = inferior; ivs = interventricular septum; LAD = left anterior descending artery; LV = left ventricle; P = posterior; RAO = right anterior oblique; RV = right ventricle; S = superior.
52
LEFT CORONARY ARTERY ANElJRYSMs IN KAWASAKI DISEASE
with the parasternal horizontal approach. The images of the peripheral left coronary aneurysms, although not perfect, coincided well in size, shape, and anatomic position with the angiographic appearances later confirmed. With regard to the proximal segments, the parasternal horizontal approach is better than the subcostal approach because the former can detect coronary arteries on a long axis. In this study, why the peripheral coronary aneurysms were not detected in the parasternal or apical approach without large aneurysms is an important question. The peripheral LAD aneurysms could be visualized using the parasternal short-axis view of the left ventricle at the level of the mitral valve papillary muscles. The parasternal short-axis view of the left ventricle at the level of the mitral valve ring and a parasternal or apical 4chamber view should be useful for visualizing the peripheral portion of the LC artery. It is probable that we were not able to visualize peripheral coronary artery aneurysms in the parasternal views because we used a 3 MHz transducer focused at 7.5 cm. If we had used a transducer with a shorter focus, we might have been able to see these aneurysms from the precordial views. Although the peripheral coronary artery, in normal infants and children, could not be visualized with the subcostal approach, we were able to image the dilatation of the peripheral LC artery (approximately 2 by 2 mm) because of Kawasaki disease in sectors P2 and P3. This technique may be limited in distinguishing small coronary aneurysms from the normal coronary artery because the peripheral segments of the left coronary artery are cut in slices. Therefore we had to obtain confirmation by angiography in all patients whose peripheral left coronary arterial echo-free spaces were visualized by subcostal approach. Because patients who underwent angiography were selected largely on the basis of their echocardiographic and clinical findings, we were unable to make any statements about false-negative results in the detection of peripheral coronary artery aneurysms. Further comparative studies with both echocardiography and coronary angiography may be required in many cases. The parasternal horizontal approach is a good technique as it can image even the normal coronary artery on a long axis, but it can image only limited areas of proximal segments. Our previous study provided a technique for detecting peripheral right coronary aneurysms with use of the subcostal approach.14 In the
present study, we describe a new technique for detecting peripheral left coronary aneurysms in both LAD and LC arteries. By combining these 3 techniques, almost all coronary aneurysms, located in either the proximal or the distal artery, can be visualized with 2-D echocardiography.
References 1. Kawasakl T, Koaaki F, Okawa S, Shigematsu I, Yanagawa H. A new infantile acute mucocutaneous lymph node syndrome (MLNS) prevailing in Japan. Pediatrics 1974:54:271-278. 2. Takao A, Kusakawa S, Hamada I, Ando M, Asal T. Cardiovascular lesions of mucocutanaous lymph node syndrome (abstr). Circulation 1974;5O:Suppl 8l:lll-39. 3. Yanagtaawa Y, Kobayaabl N. Malsuya S. Mvocardial infarction due to coron-&y thromboarte?itis following acute febrile mucocutaneous lymph node syndrome (MLNS) in an infant. Pediatrics 1974;54:277-281. 4. Kate H, Kolke S, Yamamato M, Ho Y, Tam E. Coronary anauysm in infants and young children wtth acute febrile mucocutaneous lymph node syndrcma. Pediatrics 1975;88:892-898. 5. Dnouchl 2, Tomlzawa N, Goto M, Nakala K, Fukuda Y. Cardiac involvemant and prognosis in acute febrile mucfxxrtanaous lymph node syndrome. Chest.l975;88:297-301. 8. Radford DJ, Sondeheimer HM, Williams GJ, Fowler RS. Mucocutaneous lymph node syndrome with coronary artery aneurysm. Am J Ois Child 1978;130:598-598. 7. Kttamura S, Kawaahlma Y, Kawachl K, FuJIno M, Kozuka T, Fujtta T, Manaba H. Lefl ventricular function in patients with coronary arteritis due to acute febrile mucocutanaous lymph node synrkome or related diseases. Am J Cardiol 1977;40:158-184. 6. Kegel SM, Doraey TJ, Rowen M, Taylor WF. Cardiac death in mucocutaneous lymph noda syndrome. Am J Cardiol 1977;40:282-288. 9. Fujlwara H, Hamashima Y. Pathology of the heart in Kawasaki disease. Pediatrics 1978;81:100-107. 10. Matauo H, Mataumoto M, Hamanaka Y. Direct vtsualizattt of aneurysms of coronary artery in acute febrile mucocutaneous lymph node syndrome (MCLS). Electronic sector two-dimensional echocardtNgraphy (abstr). Jpn J Mad Ultrasonic 1977;31:139-140. 11. Yoahlkawa J, Yanagthara K, Dwakl T, Kato H. Takagt Y, Dkumachl F, Fukuya T, Tomlta Y, Baba K. Crass-sectional echocan%iographicdiagnosis of coronary artery aneurysms in patients with the mucocutaneous lymph node syndrome. Circulation 1979;59:133-139. 12. Hlralabi S, Yashlro K, Kuaano S. Noninvasive visualization of coronary arterial aneurysm in infants and young children with muccc&neous lymph node syndrorim with twodimensiorial echocardiography. Am J drdiol 1979:43:1225-1233. 13. Yo+ida H, Funabaahl T, Nakaya S,. Tanlguchl N..Mucocutaneous lymph nooa syncrcme. A cross-sectronar achocardiographic diagnosis of coronary aneurysms. Am J Ois Child 1979:133:1244-1247. 14. Yoshida H, Maeda T, FunabasMT, Nakaya S, Takabalake S, Tan uchl IR. Subcostal two-dimensional echocardiograph,ic imaging of perrp %e ral r9rs:t coronary artery rn Kawasakr drsease. Crrculatron 1982;85:95615. k&Alpine WA. Heart and Coronary Arteries. Berlin: Springer-Verlag. 1975133-209. 18. Watmsley R, Watson Ht Kirklln JW. Clinical Anatomy of the Heart. Edinburgh: Churchill and Livrngstone, 1978:199-216. 17. Gensinl GG. Coronary arteriography. In: Brawnwald E. ed. Heart Disease. A Textbook of Cardiovascular Medicine. Philadelphia: WB Saunders, 1980:308-362. 18. Lange LW, Sahn DJ, Allen HD, Goldberg SJ. Subxiphoid cross-sectional echocardiography in infants and children with congenital heart disease. Circulation 1979;59:513-524. 19. Blerman FZ, Wllllatns RG. Subxiphoid two-dimensional imaging _ _ of the interatrial septum in infants and neonates with congenital heart disease. Circulation 1979:60:80-90. 20. American Heart Association Committee Report. A reporting system on patients evaluated for coronary artery disease. Circulation 1975; 51 [Suppl]:7-40. 21. Goldberg SJ, Allen HD, Sahn DJ. Pulmonary stenosis. pediatric and Adolescent Echocardiography. 2nd ad. Chicago. London: Year Book Medical. 1980:204-212.