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Sudden Cardiac Arrest in Children and Adolescents Coronary Artery Abnormalities PDF

43 Pages·2011·1.71 MB·English
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Sudden Cardiac Arrest in Children and Adolescents OOtthher causes off SSCCAA Coronary artery abnormalities Myocarditis Commotio Cordis SCA Symposium CHOC/UCI January 14, 2011 Coronary Artery Abnormalities January 14-15, 2011 SCA Conference 1 Maron BJ, et al. Sudden death in young competitive athletes: clinical demographic and pathological profiles. JAMA. 1996;276:199-204. Coronary artery abnormalities •• AAnnoommaalloouuss oorriiggiinn ooff tthhee lleefftt ccoorroonnaarryy aarrtteerryy from the pulmonary artery (ALCAPA) • Origin of the coronary artery from the opposite sinus of Valsalva • Coronary artery fistulae • KKawasakkii ddiisease • Atherosclerotic coronary artery disease January 14-15, 2011 SCA Conference 2 Coronary artery abnormalities •• AAnnoommaalloouuss oorriiggiinn ooff tthhee lleefftt ccoorroonnaarryy aarrtteerryy from the pulmonary artery • Origin of the coronary artery from the opposite sinus of Valsalva • Coronary artery fistulae • KKawasakkii ddiisease • Atherosclerotic coronary artery disease Coronary artery from the opposite sinus of Valsalva •• WWhhiicchh ccoorroonnaarryy aarrtteerryy hhaass tthhee aannoommaalloouuss origin? •Right or left • What is it’s course? •Intramural, intrarterial ••IInnttrraammyyooccaarrddiiaall • What are the patient’s symptoms if any? • What to do and when? January 14-15, 2011 SCA Conference 3 Coronary artery anomalies • Byyron H •“Healthy” 14 year old •March 2001, sudden cardiac arrest while playing basketball at community center •CPR performed, defibrillation 15 minutes llaatteerr ((ppaarraammeeddiiccss)) •Transfer to CHW, severe DCM Coronary artery anomalies •• BByyrroonn’ss sseevveerree LLVV ddyyssffuunnccttiioonn:: •Primary? •History suggests that he was asymptomatic •Secondary to the prolonged arrest and fibrillation? •Most likely scenario January 14-15, 2011 SCA Conference 4 Coronary artery anomalies •• BByyrroonn HH. •Balloon pump then mechanical cardiac support with ECMO for 72 hours •Past history: This was the 4th episode of syncope in the last 2 years •CCaarrddiiaacc wwoorrkk-uupp iinn RRaacciinnee 11 yyeeaarr pprreevviioouuss with echocardiogram, tilt, EP – all “normal” Coronary artery anomalies •• EEcchhooccaarrddiiooggrraamm •Transthoracic •TEE January 14-15, 2011 SCA Conference 5 Coronary artery anomalies Ao Anomalous origin of LCA from right sinus of Valsalva January 14-15, 2011 SCA Conference 6 Coronary artery anomalies •• BByyrroonn HH. •Weaned from ECMO after 72 hours with full recovery of LV function •Taken to OR for ECMO decannulation and “unroofing” of LCA into left sinus of Valsalva •FFuullll nneeuurroollooggiicc rreeccoovveerryy, ddiisscchhaarrggeedd 33 weeks after admission January 14-15, 2011 SCA Conference 7 AOCA from the Opposite Sinus with an Interarterial Course—Anatomic Features Aorta Cx R L Cx R L LMCA RCA LAD LAD Pulmonary trunk LCA from right sinus RCA from left sinus AOCA: Sudden Death Risk (cid:131) LCA from right sinus of Valsalva is rare (0.03%) but clearly associated with sudden cardiac death (cid:131)2299//338811 andd 3366//449922 carddiiac ddeatthh (cid:131)23/23 <20 yrs died suddenly with exercise1 (cid:131)Majority of exercise-induced SD were asymptomatic 1,3 (cid:131) RCA from the left sinus of Valsalva is more common (0.1%) but also associated with sudden cardiac death 15/52 cardiac death; 13 sudden cardiac death2 (cid:132) All 13 SD were asymptomatic (cid:132) 8/25 sudden cardiac death; 6/8 were 16-33 yrs1 (cid:132) From:1Roberts WC, Am Heart J 1986; 111 2Taylor AJ et al , J Am Coll Cardiol 1992; 20 3Frescura C et al, Hum Pathol 1998; 29 January 14-15, 2011 SCA Conference 8 AOCA: Which is Riskiest? (cid:131) Largest retrospective review of SCD in military recruits ffrroomm 11997777--22000011 (cid:131)64 sudden deaths classified as cardiac among 6.3 million recruits (cid:131)39/64 died with coronary pathology at autopsy (cid:131)54% had AOCA (left from right sinus) (cid:131)26% had obstructive atherosclerotic CAD (cid:131)(cid:131)00%% hhaadd AAOOCCAA ((rriigghhtt ffrroomm lleefftt ssiinnuuss)) (cid:131)50% had symptoms Eckhart RE et al, Cardiology in Review 2006; 14 Anatomy of CCAA Associated with SCD (cid:131)Certain anatomic subtypes of anomalous coronary oriigiin carry hhiighher riiskk off acutte myocarddiiall complications (cid:131)Anomalous origin of a coronary artery (AOCA) from the opposite sinus with an interarterial course Interarterial: (cid:131)coursing between the great arteries IInnttrraammuurraall:: (cid:131)coursing within the wall of the aorta Intramyocardial: (cid:131)coursing through the myocardium January 14-15, 2011 SCA Conference 9 AAnnoommaalloouuss oorriiggiinn ooff tthhee LLMMCCAA ffrroomm tthhee rriigghhtt ssiinnuuss ccaann hhaavvee aa vvaarriiaabbllee ccoouurrssee AAAA))AAntteriiorttoPPAA BB)BetweenAoandPA AA BB -interarterial CC)Inventricularseptum -intramyocardial DD)PosteriortoAo CC DD From Roberts and Shirani, Am J Cardiol 1992; 70 AOCA with an intramural course: runs within the wall of the aorta Features -separate orifice -acuteangle take-off -may have ostial stenosis -exits aortic wall from appropriate sinus then courses normally -surgiicall unrooffiing ttechhniique iiddeall LCA from right sinus January 14-15, 2011 SCA Conference 10

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1. Sudden Cardiac Arrest in. Children and Adolescents. Oth f SCA. Other causes of Pulmonary trunk. AOCA: Sudden Death Risk . ▫How can we risk stratify each patient? ▫Reviewed from the left sinus, surgical therapy remains Two of the cases demonstrated eosinophil and neutrophil aggregates.
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