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[00:00:00]What Z score system has been used has been mentioned in the eco report. So that if this goes to some other unit they can also compare this patient that we have understood now. So accurate weight and height do the same jet score system is important and when to do eco nowadays frequency has been increased by recent guidelines.

[00:00:18]you do more eco. Earlier we also doing more eos. I think we doing always doing aggressive in eco but now guidelines have come into picture that you say you do more eos still if the child is in the hospital and not improving you are doing every day also but child is improving maybe in 3 days 4 days you can do the eco but yeah just the the clinical features will decide when to repeat the eco. If child is not responding maybe in daily you are doing three four days daily eco. The child is three days old child you may not repeat on fourth day you will repeat on fifth or sixth day.

[00:00:49]So that will matter because in first five days I have rarely seen a coronary arty involvement or dysfunction but yes we have subtle signs which start suspecting like pervascular brightness something something unusual about the heart that is true and one more point I want to like to add here is if you're sending a patient for eco in first 5 days it has to be serated eco child is irritable eddy fever you will not get a good window forget about the jet scores so you ensure that it's job of the eco cardiographer that the child has to be fed well fever free at that stage given sedation to do the basic eco assessment otherwise in a crying child coronary arteries will not be accurate measurements and you will mess up with the reports >> so in continuation only I you can take this question also sir like >> again that child is clinically improving but serial echo cardiography shows increasing coronary artery scores and again to highlight and reiterate that use the same calculation scores because if you use different G-cores then there may be a calculation difference and like several people have seen that if you use a like there are several at least five to seven G-cores systems are available and if you use a Gcores A in comparison to B there will be almost change of more than one plus G scores so don't don't don't use that uh different G scores in a patient so how should coronary art aneurysms be classified when you are having aneurisms and why should the same J scores again if you can reiterate that that is important >> that we discussed the Jed score equation has to be same method as we understand same system has to be followed so that the if this goes to some other unit at least child is been taken care well the this has been defined recently now and uh the dilotation only is 2 to 2.5 now here I would say you know I have reservation about this criteria lot of fewer patient without Kawasaki would have this 2.2 2 2.3 so this is very non-specific but let's let's go with the clinical system here that other labs that less than 2.5 is Kawasaki I'm still not able to digest this part but but anyway we are doing it because most of their clinical criteria along with it and then small anisms 2.5 to 5 medium 5 to 10 and large more than 10 or absolute dimension of more than 8 mm now we had discussion in our unit also why absolute dimension of more than 8 mm Why not seven? Why not 10? So they they found that this has more chance of rupture. More than 8 mm is absolute value irrespective of the age that they can rupture or they can thrombose.

[00:03:29]That's why there absolute value comes into picture when talking about more than 8 mm. So jet scores are reliable and uh should be done in all the cases.

[00:03:37]Of course you maintain the discipline as I say be meticulous about the dimensions and sometimes you know LEDs proximal and distal part also should be seen.

[00:03:47]Sometimes dist is more dilated and proximal is less dilated. So make sure in our team we make sure that RC origin RC mid RC dist are defined similar LED LED proximal LED dist also defined. So that that if is seen very well that means you can measure it that means possible this dilating so maybe next 40 hours will give you a better values. So try to have more measurements and and more sedation in the these cases of measurements.

[00:04:19]>> So Dr. Nas has highlighted two through three important things. One is that whenever you are doing a echo in child sedative echo is required and that is a very important because in a seeing a coronary artery and even in a smaller child in a struggling child is a very difficult thing. So the involvement of pediatric resident is essential whenever you are doing echoc cardiorgraphy. It should not be just do echoc cardioraphy.

[00:04:43]Second thing is height and weight that should be very accurate. Even if one or two cm change in height can change your gcores weight 1 kg or 2 kg difference can change your G-course. So that that again a problem. So take a accurate height and weight and that is also a very difficult thing doing in a struggling sick child taking an accurate height and accurate accurate length in a less than two years is a very very important things and third thing which has been highlighted is that 2 to 2.5 5G scores which is a which can seen in a fibride but the context is most important if you are suspecting a coveret disease and your diagnosis clinically you are diagnosing a coveret disease in that context 22 to2.5g These scores can be taken as a coronary art of abnormalities and the good part about these coronary arties are these are transient. And fourth thing which has highlighted is that absolute diameter of the about the giant anorisms and Japanese has still still not very having an acceptance about these G-cores and they say that if their G-course the diameter based diameter based coronary artery assessment is still holds true that is because if you are having a coronary artery diameter which is beyond 8 mm and more recently it has been defined as a more than 6 mm also has a very high risk features of development of coronary artery anor ruptures and also long-term equally to develop a coronary artery disease in these patients. So those things are very important when you are dealing with a cover disease patient.

[00:06:12]>> So one more thing for the periodic residents when the patient is coming for eco it should not be after sampling if coming after sampling it will not allow the eco. So eco not be done on that day eco will be done next day then so first eco and then sampling. So uh again uh that some like now echo is a standard of care and echo is the imaging of the choice in Kawasaki disease of the patients and so but sometimes you may not be able to see all all the things which you want to see. So again an 8-month old child with KD had a proximal AD and RCAO distal segments and LCX are poorly visualized because of because of several reasons and some sometimes you have a severe teicardia and limited windows also and repeat echo is suggesting some progression but anatomy is still not clear. So, so is there any role of CT coronary angography in these patients and what does CTC add and information beyond echoc cardioraphy and there there is some update in the AHA 2024 statements about the role of CT cardigraphy in these patients. So uh if you were there last time a lot of manful Singh has come last time and we had lot of discussion about CT scan and I accept that uh we don't do CT routinely in our unit but now we have moved on gradually so CT because we understand distal part is not seen but mind you proximal part in an infant is very well seen proximal mid part of circ LD and RC are very well seen so most of the patients would have proximal involvement ment not dist has to be understood and accepted. Now few patients will have isolated distal involvement only there CT may be helpful. So only those substrates whereas thinking that this is strongly Kawasaki resistant to IVIG and I'm not sure what is happening with the child in my unit I would say no CT has been done here possibly we are missing the distism alone but if you have a proximal anism I don't see a point to do CT scan today miss in the active phase if it's a very giant anism even then I'm not interested in looking at dist part today for the long term after 6 months one year I see a point that maybe this I need to see to decide to about anticogulant or to decide therapy but in current state in acute stages the guidelines for CT will remain limited and they will remain only when you say my patient is kavasaki eco is normal and patient not responding to my standard therapy then I would like to see whether I have a distendm and distendm It can can be septic enism also. It's not only kawasaki. Can we have staff an enzysms you can have a some other cause of coronary involvement in distal part also. So that may be helpful in acute stages. So what CTC adds of course this will evaluate distal part but do we need to see dist part is to be decided and that has to be a clinical judgment but yes for a long-term followup see it is will be done and it will be more and more used in future.

[00:09:24]Thank you sir uh for highlighting this issue and he has highlighted beautifully the dilemma of the evolving evolving literature about the CT corneary angography in these patients and the recent 2 to 2024 has suggested that if you are having a giant aneurysms there is a some some role of CT corneography in denalating the coronary artery abnormalities maybe you are dealing with a complex aneurysms there may be a distal aneurysm which which is having a thrombus those things can be can be picked but again this is this is not uniform and again the literature would support support but the definitive role in a long-term follow-up is there about the city graph in these patients >> so in acute stage if they have giant anism suppose I have a proximal ready giant anism my therapy remains same whether it's a distism also involved will not change my management unless there thrombus but even then I'm anyway giving anticogulant so in the giant anism if has a Proximalism I am doing the same management.