Andersons pediatric cardiology 1395
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FIG.53.5 Echocardiographicevaluationofcoronaryarteries.(A)Shortaxisviewdemonstratinggiantaneurysmoftheleftmaincoronaryartery
andleftanteriordescendingcoronaryartery(arrows).(B)Short-axisview
demonstratinggiantaneurysmoftheproximalrightcoronaryartery(arrow).
(C)Apicalviewdemonstratinganeurysmofthedistalrightcoronaryartery
(arrow).
Echocardiographyshouldbeperformedassoonasthediagnosisissuspected
butwithoutdelayingtreatmenttoprovideabaselineexaminationofcoronary
dimensions,leftventricularfunction,valvarregurgitation,andpericardial
effusion.Theinitialechocardiograminthefirstweekofillnesscanbenormal
anddoesnotruleoutthediagnosis.Inchildrenyoungerthan3yearsorin
uncooperativechildren,asedatedstudymaybenecessarytoobtainagood
assessmentofthecoronaryarteries.Inchildrenwhosefeverresolvesafterinitial
treatmentwithintravenousimmuneglobulinandwhoremainafebrile,
echocardiographyshouldberepeatedwithin1to2weeksandagainat4to6
weeksaftertreatment.2Childrenathigherrisk—thatis,thosewithrecrudescent
fever,baselinecoronaryarteryabnormalities,diminishedleftventricular
function,orpericardialeffusion—shouldundergomorefrequent
echocardiographicevaluationtoguidetheneedforadditionaltherapies.Failure
toescalatethromboprophylaxisattimeofrapidaneurysmalexpansionisa
primarycauseofmorbidityandmortality.2
Two-dimensionalechocardiographicimagingshouldbeperformedwitha
transducerofthehighestfrequencyavailableandrecordedinadynamicvideoor
digitalcineformat.Theimagingplanesandtransducerpositionsrequiredfor
optimalvisualizationofthecoronaryarterysegmentsaredepictedinBox53.2.
Wheneverpossibleallmajorcoronaryarterysegmentsshouldbevisualized.
Multipleimagingplanesandtransducerpositionarerequiredforoptimal
visualizationofallmajorcoronaryarterysegments.Themostcommonsitefor
formationofaneurysmsaretheproximalsegmentsoftheproximalleftanterior
descendingandrightcoronaryarteries,followedindescendingorderbytheleft
maincoronaryartery,thecircumflexartery,thedistalpartoftherightcoronary
artery,andthejunctionbetweentherightcoronaryarteryandinferior
interventricularartery.Measurementsaremadefrominneredgetoinneredge
excludingpointsofbranching.Aneurysmsareconsideredtobesaccularwhen
theiraxialandlateraldiametersarenearlyequal.Fusiformaneurysmsoccur
whenthereissymmetricdilationwithgradualproximalanddistaltapering.
Coronaryarteriesthataredilatedwithoutasegmentaneurysmareconsidered
ectatic.
Box53.2
EchocardiographicViewsofCoronary
ArteriesinPatientsWithKawasakiDisease
▪LMCA:Precordialshortaxisatlevelofaorticvalve;precordiallongaxisof
leftventricle(superiortangential);subcostalventricularlongaxis
▪LADcoronaryartery:Precordialshortaxisatlevelofaorticvalve;
precordialsuperiortangentiallongaxisofleftventricle;precordialshort
axisofleftventricle
▪Leftcircumflexbranch:Precordialshortaxisatlevelofaorticvalve;apical
fourchamber
▪RCA,proximalsegment:Precordialshortaxisatlevelofaorticvalve;
precordiallongaxis(inferiortangential)ofleftventricle;subcostalcoronal
projectionofrightventricularoutflowtract;subcostalshortaxisatlevelof
atrioventriculargroove
▪RCA,middlesegment:Precordiallongaxisofleftventricle(inferior
tangential);apicalfourchamber;subcostalleftventricularlongaxis;
subcostalshortaxisatlevelofatrioventriculargroove;RCAproximal(1)
andmiddle(2)observedintheatrioventriculargroovefromthethird
intercostalspaceattheleftandrightsternalborder
▪RCA,distalsegment:Apicalfourchamber(inferior);subcostalatriallong
axis(inferior)
▪Posteriordescendingcoronaryartery:Apicalfourchamber(inferior);
subcostalatriallongaxis(inferior);precordiallongaxis(inferiortangential)
imaging;posteriorinterventriculargroove
LAD,Leftanteriordescending;LMCA,leftmaincoronaryartery;RCA,right
coronaryartery.
FromMcCrindleBW,RowleyAH,NewburgerJW,etal.Diagnosis,treatment
