Comparison Between Currently Recommended Long-Term Medical Management of Coronary Artery Aneurysms After Kawasaki Disease and Actual Reported Management in the Last Two Decades

Kawasaki Disease in the Time of COVID-19 and MIS-C: The International Kawasaki Disease Registry

BACKGROUND

Patients with multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease (KD) have overlapping clinical features. We compared demographics, clinical presentation, management, and outcomes of patients according to evidence of previous SARS-CoV-2 infection.

METHODS

The International Kawasaki Disease Registry (IKDR) enrolled KD and MIS-C patients from sites in North, Central, and South America, Europe, Asia, and the Middle East. Evidence of previous infection was defined as: Positive (household contact or positive polymerase chain reaction [PCR]/serology), Possible (suggestive clinical features of MIS-C and/or KD with negative PCR or serology but not both), Negative (negative PCR and serology and no known exposure), and Unknown (incomplete testing and no known exposure).

RESULTS

Of 2345 enrolled patients SARS-CoV-2 status was Positive for 1541 (66%) patients, Possible for 89 (4%), Negative for 404 (17%) and Unknown for 311 (13%). Clinical outcomes varied significantly among the groups, with more patients in the Positive/Possible groups presenting with shock, having admission to intensive care, receiving inotropic support, and having longer hospital stays. Regarding cardiac abnormalities, patients in the Positive/Possible groups had a higher prevalence of left ventricular dysfunction, and patients in the Negative and Unknown groups had more severe coronary artery abnormalities.

CONCLUSIONS

There appears to be a spectrum of clinical features from MIS-C to KD with a great deal of heterogeneity, and one primary differentiating factor is evidence for previous acute SARS-CoV-2 infection/exposure. SARS-CoV-2 Positive/Possible patients had more severe presentations and required more intensive management, with a greater likelihood of ventricular dysfunction but less severe coronary artery adverse outcomes, in keeping with MIS-C.

Edoxaban for Thromboembolism Prevention in Pediatric Patients With Cardiac Disease

BACKGROUND

Standard of care (SOC) anticoagulation for thromboembolism (TE) prevention in children with cardiac disease includes low molecular weight heparins or vitamin K antagonists. Limited data exists for alternate use of direct oral anticoagulants in children.

OBJECTIVES

The investigators aimed to obtain safety and efficacy data for edoxaban in children.

METHODS

We performed a phase 3, multinational, prospective, randomized, open-label, blinded-endpoint trial in patients <18 years of age with cardiac disease (ENNOBLE-ATE [Edoxaban for Prevention of Blood Vessels Being Blocked by Clots (Thrombotic Events) in Children at Risk Because of Cardiac Disease] trial). Patients were randomized 2:1 to age- and weight-based oral edoxaban once daily vs SOC for 3 months (main study period), stratified by cardiac diagnosis. Both groups could continue in an open-label edoxaban extension arm through 1 year. The primary endpoint was adjudicated clinically relevant bleeding (CRB). The main secondary endpoint was symptomatic TE or asymptomatic intracardiac thrombosis.

RESULTS

The modified intention-to-treat cohort included 167 children. One patient per group experienced a nonmajor CRB in the main period. Treatment-emergent adverse events occurred in 46.8% (51 of 109) with edoxaban and 41.4% (24 of 58) with SOC. One SOC patient experienced 2 TE events (DVT with PE). Among 147 children in the extension, 1 CRB event (0.7%) and 4 TEs occurred (2.8%; 2 strokes and 2 of 33 Kawasaki disease patients with coronary artery thromboses and/or myocardial infarctions).

CONCLUSIONS

Edoxaban is a potential alternative mode of thromboprophylaxis in children with cardiac disease showing low rates of CRB and TEs with advantages of once daily dosing and infrequent monitoring requirement. (ENNOBLE-ATE [Edoxaban for Prevention of Blood Vessels Being Blocked by Clots] (Thrombotic Events) in Children at Risk Because of Cardiac Disease trial; NCT03395639).

Surgical treatment of coronary artery lesions in children with Kawasaki disease

OBJECTIVES

This study aimed to explore the efficacy of different surgical treatment for coronary artery lesions (CALs) caused by Kawasaki disease (KD) in children.

METHODS

We retrospectively analyzed the records of children with KD who presented with CALs to our hospital between 2015 and 2022. The patients were aged 126 ± 44.3 months (range: 84-180 months), and their body weight was 37.1 ± 18.6 kg (range: 17-60 kg). All patients were diagnosed with KD and were treated with standard medications. The patients had CALs for an average of 78 months (range: 24-156 months). All children underwent surgical treatment. In addition, one patient underwent cardiac defibrillator implantation, two underwent coronary artery bypass grafting (CABG), and one underwent heart bypass transplantation. The internal thoracic artery was used as the source of the left anterior descending branch bridge tube. The no-touch technique was used to obtain the free right thigh great saphenous vein as the bridge tube of the right coronary artery.

RESULTS

All four patients had good postoperative recovery and the cardiac ultrasonography showed improved cardiac function and smooth coronary artery blood flow. The preoperative left ventricular ejection fraction was 44 ± 23.4%, which was significantly improved to 61.4 ± 14.0% postoperatively (p > .05). The preoperative left ventricle size was 5.6 ± 1.6 cm, which was significantly improved to 4.0 ± 0.6 cm postoperatively (p > .05). The two patients who underwent CABG received oral aspirin (5 mg/kg) and clopidogrel (1 mg/kg) antiplatelet therapy. The patients received oral tacrolimus antirejection drugs after the heart transplantation. The postoperative cardiac function was above grade II, and there were no symptoms of cardiac insufficiency, such as syncope, chest tightness, and orthopnea.

CONCLUSIONS

Patients with CALs due to KD should be treated in a timely manner. The selection of an appropriate surgical treatment leads to prolonged survival and improved quality of life of patients.

Kawasaki Disease Arab Initiative [Kawarabi]: Establishment and Results of a Multicenter Survey

Studies on Kawasaki disease (KD) in Arab countries are scarce, often providing incomplete data. This along with the benefits of multicenter research collaboratives led to the creation of the KD Arab Initiative [Kawarabi] consortium. An anonymous survey was completed among potential collaborative Arab medical institutions to assess burden of KD in those countries and resources available to physicians. An online 32-item survey was distributed to participating institutions after conducting face validity. One survey per institution was collected. Nineteen physicians from 12 countries completed the survey representing 19 out of 20 institutions (response rate of 95%). Fifteen (79%) institutions referred to the 2017 American Heart Association guidelines when managing a patient with KD. Intravenous immunoglobulin (IVIG) is not readily available at 2 institutions (11%) yet available in the country. In one center (5%), IVIG is imported on-demand. The knowledge and awareness among countries' general population was graded (0 to 10) at median/interquartiles (IQR) 3 (2-5) and at median/IQR 7 (6-8) in the medical community outside their institution. Practice variations in KD management and treatment across Arab countries require solid proactive collaboration. The low awareness and knowledge estimates about KD among the general population contrasted with a high level among the medical community. The Kawarabi collaborative will offer a platform to assess disease burden of KD, among Arab population, decrease practice variation and foster population-based knowledge.

Short-term Cardiovascular Complications of Multi-system Inflammatory Syndrome in Children (MIS-C) in Adolescents and Children

Purpose of Review

We provide the readers with a review of cardiac complications in children with multi-system inflammatory syndrome in children (MIS-C) and its short-term outcomes.

Recent Findings

Recent reports described the acute cardiac manifestations of MIS-C in children and provided a glimpse of the short-term outcomes.

Summary

Children with MIS-C have been reported to acutely have variable degrees of cardiac findings including abnormal cardiac enzymes, abnormal electrocardiographs, decreased systolic function, coronary artery abnormalities from coronary dilation to giant aneurysms, mitral valve regurgitation, tricuspid valve regurgitation, aortic valve insufficiency, pericardial effusion, diastolic dysfunction, abnormal cardiac strain, and abnormal cardiac MRI. The majority of these abnormalities resolved during short-term follow-up. Further studies are needed to assess if transient or persistent cardiac complications are associated with long-term adverse cardiac events in children with MIS-C.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40124-021-00258-5.