Home » 2009 » 09-08

Number 09-08 Syncopal Event in a Case of Kawasaki's

Anna Herrey, Vivienne Ezzat, Rory O'Hanlon, Marina Hughes, Malcolm Walker, James Moon.
The Heart Hospital, London, UK.

Clinical history: A 22 year old woman with a history of Kawasaki's disease diagnosed aged 8 presented with a syncopal event. Echocardiography demonstrated an inter-atrial septum aneurysm. CMR was requested to define the coronary anatomy and evaluate the inter-atrial septal aneurysm. 

CMR: The 4-chamber SSFP and FLASH sequenced cine images demonstate the atrial septal aneurysm. FLASH cine imaging in this regard nicely demonstrates greater degrees of fresh inflow enhancement and potentially allows imaging of flow around the atrial septal region. Alternatively an inplane flow map across the atrial septal region can be performed. The RV was undilated.

SSFP

FLASH

The atrial SSFP images allow closer scrutiny of this region. Flow mapping did not demonstrate any L-R shunt (Qp:Qs 1.0)- Aortic  and Pulmonary SV 83ml and 79ml by flow mapping respectively, and 85ml and 78ml by standard volumetric analysis. While a small PFO cannot be definitely ruled out, there is certainly no significant ASD associated with the atrial septal aneurysm. An inplane and through-plane flow map across the atrial septum did not demonstate a L-R flow/shunt (not shown).

Aortic Flow Mapping

Pulmonary Flow Mapping

Finally, a non-breathold navigator 3D coronary acquisition was performed.  Coronary images are best acquired by optimally timing diastasis (white arrows) using a high temporal resolution SSFP 4 chamber cine.

Timing for diastasis

The coronary images demonstrates non-dilated coronary arteries with normal origin and proximal course. Reformatting with Osirix demonstrate and separate the great cardiac vein from the coronaries showing no evidence of coronary involvement by Kawasaki's.

Non Breathhold Navigator 3D Whole Heart Sequence

Osirix reformatting

Perspective: This case nicely highlights how CMR can be used to address several clinical questions in a single scan setting, avoiding the need for TEE+/- bubble study (?PFO ?ASD), CT Coronaries (aneurysmal dilatation due to Kawasaki's), and potentially R+L heart catheterisation (Qp:Qs).
Full CMR dataset here
Reference: "How I do" anomalous coronaries (Gavin Bainbridge, Sven Plein, John Greenwood, Leeds)

Submit your case here

COTW handling editor: Rory O' Hanlon