Mid to long-term results of circumflex coronary artery revascularization with left internal thoracic artery grafts

The current trend in coronary artery surgery is to revascularize the left coronary artery branches with bilateral internal thoracic arteries (ITA). For this procedure, the right ITA is usually grafted to the left anterior descending coronary artery while the circumflex coronary artery is revascularized by the left ITA. The mid to long-term results of the left ITA on the circumflex system were examined in this study. Forty of 48 patients operated on between 1996 and 1998 who had undergone revascularization of the left coronary artery with both ITAs and who fulfilled the study criteria underwent control coronary arteriography to determine the mid to long-term patency of LITA grafts on the circumflex artery. The median time for follow-up was 53 months (range, 49 to 70 months). Of the 40 angiographically controlled patients, 35 had patent left ITA to circumflex artery anastomosis (87.5%). One graft stenosis and four graft occlusions were observed. In the same group, right ITA to left anterior descending coronary artery anastomoses were patent in 38 patients (95%). Left ITA grafts seem to be the conduit of choice for revascularization of the circumflex coronary artery. In combination with the in situ right ITA to left anterior descending coronary artery anastomosis, in situ left ITA grafting to the circumflex system can be done with acceptably low mortality and excellent long-term patency rates. Its utilization is particularly advised in young patients where the importance of left coronary artery revascularization by bilateral ITA grafts is increased.     

Stenting of coronary artery stenosis in Kawasaki disease

Coronary artery lesions can develop in Kawaski disease as a major complication, and result in aneurysm formation and stenosis. Reported is the evolution of important coronary artery stenosis in a pediatric patient managed with an endovascular stent. Cathet. Cardiovasc. Intervent. 46:333–336, 1999. © 1999 Wiley-Liss, Inc.     

Evaluation of patency of internal mammary artery grafts: a comparison of two-dimensional Doppler echocardiography with coronary angiography

To examine the clinical feasibility of color flow mapping Doppler echocardiography (CFM) in diagnosing the patency of internal mammary artery (IMA) grafts, 41 patients who had had coronary bypass surgery were examined by both CFM and coronary angiography (CAG) within one week of the CFM examination. Coronary bypass surgery was performed one to eight months prior to this study, and the average number of bypass grafts was 2.7 +/- 0.7. The patency of the IMA grafts was confirmed in all except one patient by CAG; whereas, the flow in the IMA grafts was clearly visualized in all 22 patients by CFM from the left parasternal echo window. Peak velocities of the IMA graft flow in the 22 patients were 31.7 +/- 12.0 (19-49) cm/sec in diastole and 14.9 +/- 8.5 (5-36) cm/sec in systole. No false positive diagnosis was made in the CFM examination. The sensitivity, specificity, negative predictive value, and positive predictive value of CFM in the diagnosis of IMA graft patency were 55%, 100%, 5.3% and 100% respectively. In conclusion, although the sensitivity of color Doppler still remains relatively low, its specificity in the diagnosis of IMA graft patency is 100%. Thus, color Doppler is expected to be valuable for long-term follow-up of IMA graft patencies.     

Experience of double internal thoracic artery grafts in coronary artery revascularization

We have started employing two internal thoracic artery grafts in coronary artery revascularization since February 1988. We have carried out seven such operative procedures in a 15 month period since then. Ages ranged from 55 to 67 years with a mean of 60.6. Six patients were male and one patient was female. One patient was in Canadian Cardiovascular Society angina Class I, one in Class II, four in Class III, and one in Class IV, preoperatively. There were no operative deaths. Postoperatively, six patients were in CCS Class I and one was in Class II. All of the internal thoracic artery grafts were patent at hospital discharge in six angiographically examined patients. We feel that use of double internal thoracic artery grafts in coronary revascularization carries minimal additional risk, when performed in selected case.     

Mid-to-long-term patency comparison of the right internal thoracic artery grafts on the left anterior descending and on the right coronary arteries

BACKGROUND: The excellent results obtained from internal thoracic artery for myocardial revascularization have led surgeons to simultaneous use of other arterial conduits, particularly the right internal thoracic artery. However, some controversy still exists regarding the optimal target coronary artery for this graft; different strategies have been proposed for bilateral internal thoracic artery grafting. PATIENTS AND METHODS: 59 patients with right internal thoracic artery grafts were monitored using coronary arteriography in order to compare the patency of this graft on the left anterior descending and the right coronary arteries. The right internal thoracic artery was grafted to left anterior descending artery in 39 patients (group 1) and to right coronary artery in 20 patients (group 2). RESULTS: The mean period of follow-up was 64.07 months (range: 37 to 185 months). Overall, 8 of the 59 grafts (13.6%) were occluded at the arteriography. In group 1, 1 of 39 (2.6%) grafts and in group 2, 7 of 20 (35%) grafts are found to be occluded. These results are considered statistically significant (p < 0.001). COMMENT: The results show that the patency of the right internal thoracic artery is significantly better on the left anterior descending artery than on the right coronary artery in the mid-to-long term, and patency does not differ from the left internal thoracic artery on the left anterior descending artery.     

Long-term changes in coronary artery aneurysms in patients with Kawasaki disease: comparison of therapeutic regimens.

BACKGROUND: There are few studies of the therapeutic regimens for the prevention of stenotic transformation of aneurysms in Kawasaki disease (KD). The aim of this study was to assess the prophylactic effect of combined therapy in the acute stage and convalescent- to chronic-stage against the formation of stenotic lesions. METHODS AND RESULTS: In 85 patients, 103 giant aneurysms (ANl), 46 medium-sized aneurysms (ANm), and 13 small aneurysms (ANs) were analyzed. With respect to therapy in the acute stage, no localized stenosis of ANl in the left coronary artery was noted in patients who received high-dose gamma globulin therapy (G). For ANm, the group (G) showed a significantly higher regression rate than the aspirin group and steroids group. Furthermore, no coronary artery occlusion/recanalization of ANl occurred with the prophylactic regimen of aspirin and warfarin {aw}. Prophylaxis {aw} and the prophylactic regimen of aspirin alone {a} significantly lowered the incidence compared with either the prophylactic regimen of warfarin {w} or no prophylaxis {n}. However, no significant differences were noted between prophylaxis {w} and {n}. CONCLUSIONS: High-dose gamma globulin therapy in the acute stage of KD is the first choice for the prevention of stenotic transformation. Prophylaxis {aw} is recommended for ANl.     

Remodeling of coronary artery lesions due to Kawasaki disease: comparison of arteriographic and immunohistochemical findings

Since the original report of Kawasaki disease in 1967 more than 150,000 cases have been reported in Japan. Although there have been no nationwide epidemics in Japan since 1987, more than 6,000 newly diagnosed cases are reported every year, and the number has been increasing year by year despite the decreasing birth rate. The etiology of the disease is still unknown. High dose intravenous gammaglobulin is currently used during the acute phase in 84% of the patients in Japan with a concomitant decrease in coronary arterial sequelae. However, 7-13% of the patients still have persistent coronary artery aneurysms after the acute stage. The aneurysms are seen mostly in the proximal coronary arteries, and are often associated with aneurysms in the distal coronary artery segments (Figure 1A, 2A). Most of the patients show a decrease in the size of aneurysms soon after the acute phase (Figure 1B). However, the aneurysms may progress to obstructive lesions even after initial regression (Figures 1C, D, 2B). Such obstructive lesions may cause sudden death or myocardial infarction. Long term follow-up of coronary artery lesions has revealed several characteristic features, including progressive localized stenosis (Figure 1D), extensive recanalizations (Figure 2D) and development of collateral arteries. Progressive increases in aneurysm size and the appearance of new aneurysms in the late phase have also been reported. The basic mechanisms of the coronary arterial remodeling in Kawasaki disease have not yet been elucidated. Only recently has immunohistochemical staining in formalin-fixed specimens become feasible. This is a major technical breakthrough since it is almost impossible to obtain fresh frozen specimens of coronary artery lesions of Kawasaki discase. In this paper, we compare immunohistochemical findings in coronary artery lesions with the corresponding coronary angiographic findings, and attempt to make inferences as to the mechanism of remodeling both in early and late phases of the disease based on the expression of vascular growth factors.     

Long-term prognosis of Kawasaki disease patients with coronary artery obstruction

Summary The prognosis of coronary artery obstruction was studied in patients with Kawasaki disease. Between May 1973 and December 1987, coronary artery obstruction was diagnosed by coronary angiography in 30 patients (21 males, 9 females), of whom, only 8 (26.7%) had clinical symptoms. One patient died after 9 years of illness. Two complained of frequent chest pain, which disappeared after bypass surgery in one case and spontaneously in the other. Five had symptomatic myocardial infarction. Myocardial ischemia was diagnosed in 31.8% by treadmill stress testing, but was well demonstrated in 85.7% by thallium-201 myocardial tomography. Frequent ventricular premature beats, Wenckebachtype atrioventricular block, and ST-segment depression accompanied by chest pain were recognized by 24-h Holter monitoring. In the past, the methods used to determine the prognosis of Kawasaki disease patients with coronary artery obstruction were not adequate. However, the examinations used in this study revealed an improved ability to determine the prognosis in this disease. Myocardial tomography, in particular, provided a more accurate evaluation of myocardial damage. Ventricular arrhythmias seem to be a serious problem in these patients. Therefore, careful observation using these tests, especially myocardial tomography and Holter monitoring, should be done even if the patients are free of symptoms.     

Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study

OBJECTIVES: This study defined long-term patency of saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts. BACKGROUND: This VA Cooperative Studies Trial defined 10-year SVG patency in 1,074 patients and left IMA patency in 457 patients undergoing coronary artery bypass grafting (CABG). METHODS: Patients underwent cardiac catheterizations at 1 week and 1, 3, 6, and 10 years after CABG. RESULTS: Patency at 10 years was 61% for SVGs compared with 85% for IMA grafts (p < 0.001). If a SVG or IMA graft was patent at 1 week, that graft had a 68% and 88% chance, respectively, of being patent at 10 years. The SVG patency to the left anterior descending artery (LAD) (69%) was better (p < 0.001) than to the right coronary artery (56%), or circumflex (58%). Recipient vessel size was a significant predictor of graft patency, in vessels >2.0 mm in diameter SVG patency was 88% versus 55% in vessels 2.0 mm in diameter.     

小儿川崎病冠状动脉病变的临床探究

目的探讨小儿川崎病冠状动脉病变的临床治疗方法与治疗效果。方法选取2003年6月~2013年6月来我院接受治疗的川崎病冠状动脉病变患儿30例,采用超声心动图对这些患者冠状动脉受伤的情况进行检查,并采用Cubens的方式测定患儿左心室收缩功能的情况,采用二尖瓣多普勒血流图测定这些患者的左心室舒张功能,同时与30例正常儿童的心功能状况进行对比分析。结果在30例冠状动脉受到损伤的患儿中,有21例患儿的冠状动脉扩张情况在治疗4个月的时间内得到了控制并逐渐好转,有8例患儿的冠状动脉扩张情况在治疗6个月时间内逐渐得到好转,只有1例患儿在6个月的随访调查中发现其病情并未出现好转。结论川崎病患儿在发病时冠状动脉很容易受到影响,尤其出现在急性期,而对心功能的改变影响则不明显,临床诊断中应用超声心动图诊断效果显著,值得广泛推广和应用。     

Limb ischemia due to use of internal thoracic artery in coronary bypass

Immediately after undergoing coronary bypass grafting using the left internal thoracic artery, a 59-year-old man developed left leg ischemia. Right-to-left femoral artery crossover bypass was performed and the ischemia resolved. A 72-year-old man developed left calf pain 12 days after a similar procedure; peripheral angiography revealed stenosis of the abdominal aorta and distal peripheral arteries, which did not require intervention.     

Long-term patency of bilateral internal thoracic artery Y composite coronary artery bypass grafts—determinants and impact on survival

BackgroundBilateral internal thoracic artery Y-composite grafting with sequential anastomoses is a well-established strategy for multi-arterial coronary artery bypass grafting. This study investigated the factors affecting long-term patency of bilateral internal thoracic artery Y-composite grafts and their influence on survival.MethodsPatients who underwent coronary artery bypass grafting using bilateral internal thoracic artery Y-composite grafts due to triple-vessel disease were included. In total, 415 cases (2003–2020) with at least 1 postoperative coronary computed tomography or angiography examination were enrolled. Through a retrospective review of medical records and computed tomography, risk factors for graft events (string sign or occlusion) were analysed, and the influence of string sign or occlusion in the initial postoperative computed tomography on long-term survival was evaluated.ResultsPatients’ mean age was 66±9 years and 324 were male (78%). The mean number of anastomoses from bilateral internal thoracic artery grafts was 4.0±0.9. The mean follow-up duration was 8.0±4.0 years (interquartile range: 4.8–11.5 years). Beating-heart surgery negatively affected the patency of grafts to the left circumflex and right coronary artery territories (P=0.015 and P=0.030, respectively), but in the left anterior descending territory, the graft patency did not differ (P=0.053). Non-severe (<90%) native-vessel stenosis was a risk factor for poor patency in the left anterior descending, left circumflex, and right coronary artery territories (P<0.001 for all). Twenty-four of the 104 nonvisible or narrowed grafts (23%) on early imaging later became widely patent. Occlusion of the grafts or the string sign within postoperative 1 year did not have a negative impact on long-term survival (P=0.421).ConclusionsThe patency rate was suboptimal in case of non-severe target-vessel stenosis (<90%). The beating-heart technique may negatively influence the patency of anastomoses to the left circumflex and right coronary artery territories. Compromised graft patency observed on initial computed tomography did not lead to worse survival.     

Myocardial contrast echocardiography of coronary artery lesions due to Kawasaki disease

Summary In addition to coronary arteriography, myocardial contrast echocardiography (MCE) was performed in 25 patients with coronary artery lesions due to Kawasaki disease, in order to investigate its validity in the evaluation of these lesions and its safety in children. The patients' ages ranged from 1.0 to 15.9 years (mean, 8.6 years). Their coronary artery lesions included occlusion in 9 branches (9 patients), segmental stenosis in 9 (8 patients), localized stenosis in 16 (12 patients), and dilated lesions without coexistent stenotic lesions in 5 patients. Seven patients had coronary artery bypass grafts. Myocardial perfusion patterns of the stenotic lesions and coronary artery bypass grafts could be clearly demonstrated by MCE. For the assessment of safety, electrocardiograms obtained at the time of MCE and coronary arteriography in 14 patients showed no significant difference in the findings between MCE and coronary arteriography. Serum glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, lactic dehydrogenase, and creatine phosphokinase levels were measured before and 1 day after the procedure in 14 patients who underwent MCE and coronary arteriography, and in a group of 14 patients who underwent coronary arteriography alone. No significant difference was noted between the values of the two groups. These results suggested that MCE can be utilized in the assessment of coronary artery lesions due to Kawasaki disease, and confirmed the safety of the procedure even in young children.     

大隐静脉序贯式完全性冠状动脉血运重建远期随访

目的 回顾性研究早期冠状动脉搭桥接受2条序贯式大隐静脉行完全性冠状动脉血运重建患者的远期情况.方法 随访11例患者平均15年存活的情况和大隐静脉桥的改变情况.结果 无手术死亡,5年11例全部存活,10年10例存活,15年9例存话.3例冠状动脉造影2例4个吻合口和1例5个吻合口完全通畅,静脉桥形态良好,1例患者14年接受CTA检查,1条静脉桥因冠状动脉严重钙化而闭塞,另1条序贯式桥良好没有软斑块和钙化.结论 除影响静脉桥远期诸多因素以外,序贯式静脉桥伴高质量的吻合口也是桥远期开放的重要因素之一,应用静脉桥时要确保吻合口的质量.     

Comparison study of echocardiography and dual-source CT in diagnosis of coronary artery aneurysm due to Kawasaki disease: coronary artery disease

The identification of coronary artery aneurysm (CAA) in the acute and chronic phase of the disease is of prime importance for assessing the likelihood of acute lesions and cardiovascular sequelae. Occasionally, recognition of distal coronary artery has been proven challenging by traditional echocardiography. Our purpose was to evaluate the clinical application of two-dimensional echocardiography (2DE) for detecting CAA caused by Kawasaki disease (KD) and compare with dual-source computed tomography (DSCT). A total of 24 patients with known KD and CAAs were studied by two imaging modalities, i.e., 2DE and DSCT; that is to say, the number, position, shape, and size of each CAA and its association with thrombus, were detected first from echocardiography and then compared with those obtained from DSCT performed on the same day. Meanwhile the diameters of all coronary segments were measured for each patient. Giant aneurysms (GAs) were detected in 5 patients, small and medium coronary aneurysms were identified in 19 patients. The 2DE and DSCT have the same results of proximal coronary artery, whereas conclusion of our comparison of coronary artery visualization indicated that DSCT provided more explicit distal coronary artery than 2DE. A mural thrombus could be clearly delineated in the GAs by DSCT. The 2DE has been demonstrated to be an accurate technique to quantify CAAs in KD. However, DSCT is superior to 2DE for distal coronary artery visualization. Therefore, a combination of echocardiography and DSCT can offer an overview of coronary artery anatomy.     

Transcutaneous ultrasound assessment of internal thoracic artery to coronary artery grafts in patients with and without ischaemic symptoms.

OBJECTIVE--To evaluate transcutaneous duplex ultrasound in the assessment of internal thoracic artery to coronary artery grafts. SETTING--Regional cardiothoracic centre. METHODS--Prospective duplex ultrasound evaluation of 83 consecutive patients undergoing left internal thoracic artery to coronary artery grafts, together with combined angiographic and duplex ultrasound evaluation of 17 patients with suspected recurrent myocardial ischaemia after internal thoracic artery grafting. RESULTS--The grafted internal thoracic artery was imaged in 65 (78%) of 83 consecutive postoperative patients, and in 13 (75%) of 17 patients with suspected graft dysfunction. Grafts were recognised by their characteristic position and biphasic blood flow pattern. Resting graft flow was estimated from the time averaged velocity and graft cross sectional area. Median resting flow in patients without ischaemic symptoms was 36 ml/min (interquartile range 24 to 49 ml/min). Of 13 patients with recurrent ischaemia in whom the graft could be imaged, nine patients with estimated flow in the lowest quartile or abnormal flow profiles, or both, had graft disease or anastomotic problems on angiography, while four with satisfactory graft flow on ultrasound examination had normal graft flow on angiography, but had evidence of native disease progression in other vessels. Two of four patients in whom it was not possible to image the graft on ultrasound had satisfactory graft function on angiography. CONCLUSIONS--For those patients whose internal thoracic artery graft can be imaged, transcutaneous duplex ultrasound is a helpful non-invasive guide to graft function. The main limitations to the technique are an inability to image the graft in about 20% of patients, and possible inaccuracy in estimating graft diameter.     

Hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with internal mammary arteries in children with Kawasaki disease

BACKGROUND. Saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts have been used for coronary artery bypass grafting. In adult patients with bypass grafting for atherosclerotic coronary artery disease, IMA grafts have been reported to have long-term patency; however, results are conflicting on whether the graft is sufficient to meet increased myocardial oxygen demand during exercise. There have been no studies on hemodynamics and blood flow during exercise after bypass grafting with IMA in pediatric patients with Kawasaki disease. METHODS AND RESULTS. We studied 17 pediatric patients with Kawasaki disease (average age, 7.5 +/- 3.1 years), who underwent coronary artery bypass grafting with the IMA. The average number of coronary artery bypass grafts was 2.1 +/- 0.7/patient. For all patients, the left IMA was anastomosed to the left anterior descending coronary artery; for eight patients, the right IMA was also anastomosed to the right coronary artery. In addition, 11 SVGs were used. The postoperative patency rates after 1 month were 100% with the IMA graft and 91% with SVG. One year after the operation, the patency rates were 100% with IMA and 50% with SVG. Hemodynamics during exercise were measured with a bicycle ergometer, and coronary sinus blood flow was measured by the continuous thermodilution method in six patients. The relation between delta LVEDP (the difference between left ventricular end-diastolic pressure at rest and during exercise) and delta SVI (the difference between the stroke volume index at rest and during exercise) was analyzed. Four of six patients had reduced cardiac function before operation (delta LVEDP, positive; delta SVI, negative). However, after the operation, all patients demonstrated improvements in cardiac function during exercise (delta LVEDP, positive; delta SVI, positive). Coronary sinus flow per left ventricular mass increased after operation from 70 +/- 46 to 87 +/- 56 ml/min at rest (p less than 0.05) and from 139 +/- 118 to 183 +/- 150 ml/min during exercise (p less than 0.05). CONCLUSIONS. In conclusion, this study reveals improvements in both hemodynamics and coronary blood flow during exercise after coronary artery bypass grafting with IMA grafts in pediatric patients with Kawasaki disease.     

Detection of coronary artery stenosis in children with Kawasaki disease. Usefulness of pharmacologic stress 201Tl myocardial tomography

This study determined the feasibility and accuracy of quantitative 201Tl myocardial single-photon emission computed tomography (SPECT) after dipyridamole infusion to detect coronary obstructive lesions in children with Kawasaki disease. 201Tl distribution after dipyridamole infusion was measured in 23 normal children, and with these normal values, quantitative analysis of SPECT was performed in 49 patients. Thirty-four patients had coronary stenosis 90% or greater on angiograms. Side effects resulting from systemic vasodilation were observed in about 70%. Angina pectoris and ischemic ST changes were observed only in patients with coronary stenosis. These symptoms disappeared after aminophylline infusion. Results of visual and quantitative analysis of SPECT were compared. SPECT data were shown on two-dimensional polar maps, and the extent and severity scores were calculated. The sensitivity of SPECT for detection of overall coronary stenosis was 91% (visual analysis) and 88% (quantitative analysis). The specificity of SPECT was 60% visually and 93% quantitatively. The sensitivity of quantitative analysis to detect individual coronary stenosis was similar to that of visual analysis. However, the specificity of visual analysis to detect individual coronary artery stenosis was significantly less than that of quantitative analysis. From these data, we conclude that quantitative analysis of myocardial SPECT after dipyridamole infusion is a safe and accurate diagnostic method for identifying coronary stenosis in children with Kawasaki disease.