Comment on "Left main aneurysm and what's next?".

We would like to thank the authors of the recently published paper exemplifying a case of coronary artery aneurism [1] for two reasons – firstly, for bringing up a rare and thus unappreciated problem and secondly, for elucidating treatment options and difficult decision making in an acute setting. As paediatricians we have a strong impression that Kawasaki disease (KD) is still an underestimated cause of coronary artery disease, leading to myocardial ischemia (MI), ventricular arrhythmia, and sudden cardiac death (SCD) not only in children but at any age. It is estimated that the annual incidence is ∼10 cases per 100,000 white children < 5 years old and 10 times that in the Japanese. In untreated cases it leads to development of coronary artery aneurisms in up to 15–20% and 1.25% of overall mortality. Timely treatment limits both morbidity and mortality 10-fold but the risk cannot be fully eliminated at any time despite apparent recovery from the disease. It was proved that small aneurisms undergo pseudonormalisation of the arterial lumen, yet giant aneurisms persist for lifetime. Tsuda et al. documented a series of 12 patients with a history positive for KD aged 13 months to 27 years who died suddenly 2 months to 24 years after the onset of the disease [2]. Unfortunately, the KD etiologic factor is unknown and the first comprehensive diagnostic and treatment guidelines were published only a decade ago [3]. Moreover, it was only recently accepted that KD can present in atypical form lacking symptoms yet being equally devastating for the arteries [4]. This leads to many delayed or missed diagnoses and an increased risk of unfavourable outcome.

In the presented case of a 64-year-old man, despite a characteristic saccular shape of the aneurism, childhood medical history is unavailable and other causes cannot be easily ruled out. On the other hand, among young adults and children with MI and aneurism, KD is first to blame [5] and a detailed medical history towards KD symptoms should be taken preferably from the parents (Figure 1).

Figure 1

Angiogram of asymptomatic 5-year-old girl post Kawasaki disease showing saccular giant aneurism extending from LMCA to its both branches