Coronary Artery Bypass Grafting for Kawasaki Disease

Five patients with a history of Kawasaki disease underwent coronary revascularization at Children's Memorial Hospital (1988-2000). Acute disease occurred at 11 weeks to 5 years of age and revascularization procedures were performed at 8 months to 12 years (mean 6 years; interval from disease onset 5 months to 9 years). Surgical indications included abnormal stress testing with angiographic confirmation of severe coronary artery stenosis (n = 3), severe coronary artery stenosis with echocardiographic evidence of intracoronary thrombus (n = 1), and ischemic electrocardiogram changes and ventricular tachycardia during angiography (n = 1). All revascularization procedures used internal thoracic arteries including one free internal thoracic artery graft. There were no postoperative deaths (follow-up 1 month to 11 years). All patients are asymptomatic. One patient developed myocardial ischemia 4 years postoperatively with occlusion of the circumflex coronary artery (not previously grafted). This was treated successfully with percutaneous coronary angioplasty and stent placement. All grafts are patent with the exception of a single right internal thoracic artery graft which underwent involution 30 months postprocedure with concurrent recannulization of the right coronary artery. Coronary revascularization should be considered in the young patient with severe coronary abnormalities secondary to Kawasaki disease.     

Multidetector Row Computed Tomography for Follow-Up of Patients with Coronary Artery Aneurysms Due to Kawasaki Disease

Multidetector row computed tomography (MDCT) coronary angiography was performed using a 16-slice MDCT scanner in three children with coronary aneurysms due to Kawasaki disease. Patients were given a -blocker. Following contrast injection, all data were acquired during a 20-second breathhold. Results were compared with those of conventional coronary angiography performed previously. MDCT provided clear visualization of coronary artery aneurysms, with coronary calcifications but which had not yet progressed to stenotic lesions. Because MDCT allows noninvasive detection and exclusion of coronary obstructions, it may be able to replace repeat conventional angiography as a follow-up study for children with coronary artery disease.     

Measurements of Coronary Artery Aneurysms Due to Kawasaki Disease by Dual-Source Computed Tomography (DSCT)

Diameters of coronary artery aneurysms (CAAs) complicating acute phase KD can strongly predict the long-term prognosis of coronary artery lesions (CAL). Recently, computed tomographic angiography (CTA) has been used to detect CAL, and the purpose of this study was to determine whether coronary artery diameters measurements by CTA using dual-source computed tomography (DSCT) can be used instead of coronary angiogram (CAG) measurements. Twenty-five patients (22 males and three females) with CAL due to KD, who had undergone both CTA and CAG within one year, were retrospectively evaluated between 2007 and 2013. A prospective electrocardiogram-triggered CTA was performed on a DSCT (SOMATOM^® Definition, Siemens Healthcare, Germany). Two pediatric cardiologists independently measured the diameters of CAAs twice in each maximum intensity projection (MIP), curved multiplaner reconstruction (MPR) and CAG. We measured 161 segments in total (segment 1–3, 5–7, 11, 13). Diagnostic accuracy was expressed as κ coefficient. A Bland–Altman analysis was also used to assess the intra-observer, inter-observer and inter-modality agreement. The diagnostic quality of CTA was excellent (κ = 0.93). Excellent inter-observer agreement for the diameters of CAAs was obtained for MIP, MPR and CAG and for the intra-observer agreement. The inter-modality agreement was also excellent in measurements of CAA (MPR–CAG: y = 0.9x + 0.40, r = 0.97, p < 0.0001 MIP–CAG: y = x + 0.1, r = 0.94, p < 0.0001). These values in normal coronary arteries were also obtained. We found a significant correlation between CTA and CAG in measuring the coronary arteries. We conclude that measuring coronary artery diameters by CTA is reliable and useful.     

川崎病并冠状动脉损害的诊断和治疗

川崎病是好发于5岁以下儿童、原因不明的全身性血管炎,其主要并发症为冠状动脉损伤.冠状动脉瘤破裂、心肌梗死为其主要死亡原因.现对川崎病并冠状动脉损伤的病理、诊断、治疗及预后等方面的新进展进行总结.     

The 30-Year Outcome for Patients After Myocardial Infarction Due to Coronary Artery Lesions Caused By Kawasaki Disease

This study determined the long-term outcome for patients after myocardial infarction (MI) due to Kawasaki disease (KD). Retrospective analysis was performed for 60 patients who had experienced MI between 1976 and 2007. Their ages at the initial MI ranged from 3 months to 33 years (median, 2 years). The maximum follow-up period after the initial MI was 33 years (median, 16 years). Coronary angiography, left ventriculography, and radioisotope myocardial perfusion imaging (MPI) had been performed for 56 patients more than 2 months after MI when all were in stable condition. The survival rate and ventricular tachycardia (VT)-free survival rate were calculated after the initial MI by the Kaplan–Meier method. Both sustained and nonsustained VT were included. Furthermore, the Cox proportional hazards model was used to analyze which factors influenced the post-MI outcome and which influenced the appearance of VT. The 30-year survival rate was 62.7% (95% confidence interval [CI], 44.6–77.9%), and the 25-year VT-free survival rate after MI was 28.5% (95% CI 15.4–46.5%). The postinfarction left ventricular ejection fraction (LVEF) was related to the outcome in this population (hazard ratio 0.86; 95% CI 0.75–0.95; P = 0.002), whereas the development of VT was related to the post-LVEF and to perfusion abnormalities in MPI (P = 0.0002). The 30-year survival rate after MI was poor for the patients with a low LVEF. With aging, the existence of nonviable myocardium in the infarct area can induce fatal ventricular arrhythmia more than 10 years after the original MI.     

Intravascular Ultrasonography of an Adolescent Boy with a Coronary Artery Aneurysm Due to Kawasaki Disease

A 14-year-old boy developed coronary aneurysms during the course of Kawasaki disease. The vessel wall morphology of the coronary arteries was assessed by intravascular ultrasound imaging (IVUS). There was intimal thickening proximal to, within, and distal to a large coronary aneurysm in the left anterior descending coronary artery only 18 months after the acute onset of Kawasaki disease. Intimal thickening without calcification is a new IVUS finding within a persistent coronary aneurysm. It may indicate that the healing process, via cell proliferation is continuing, with the risk of causing a stenosis.     

Percutaneous Coronary Intervention for Acute Myocardial Infarction in a Pediatric Patient With Coronary Aneurysm and Stenosis Due to Kawasaki Disease

We report the case of an acutely ill 3-year-old female, with a previous medical history of Kawasaki disease, who presented to care with an acute myocardial infarction. We describe the coordinated therapies employed by pediatric and adult cardiologists aimed to establish coronary revascularization.     

The Fate and Observed Management of Giant Coronary Artery Aneurysms Secondary to Kawasaki Disease in the Province of Quebec: The Complete Series Since 1976

Most population-based series reporting on the coronary artery complications after Kawasaki disease (KD) originate from Japan. This study aimed to describe the complete series of KD patients from the province of Quebec in Canada, a predominantly Caucasian population. This retrospective case series was conducted by the Quebec Kawasaki Disease Registry, a multi-institutional collaboration reviewing 89.8 % of all KD cases identified by the Ministry of Health records of hospitalization for KD from the first recognized case in 1976 until 2008. This report describes the course of 38 patients (95 % Caucasians) with a diagnosis of giant coronary artery aneurysms, which represent 1.9 % of all reviewed cases and 26.2 % of those with a coronary aneurysm 5 mm or larger. The age at diagnosis was 5.52 ± 4.04 years, and the follow-up period was 9.26 ± 6.9 years. The KD diagnosis was retrospective at autopsy in two cases and via echocardiography in four cases. The overall freedom from coronary thrombi, coronary intervention, or death was respectively 63.9, 67.5, and 85.1 %. Five deaths occurred as follows: 21 days after onset of fever (2 cases), 1.8 months after onset of fever (1 case), 1 year after retrospectively presumed but previously undiagnosed KD (1 case), and 5.7 years after a KD diagnosis (1 case of sudden cardiac death). Percutaneous transluminal coronary revascularization was attempted in four cases (1 requiring cardiac transplantation), and two other cases underwent primary bypass graft surgery. Whereas this study investigated cases of KD with severe coronary sequelae in the Province of Quebec, larger collaborative studies should be conducted for further understanding of the disease in predominantly non-Asian populations.     

Age-Related Acceleration of Endothelial Dysfunction and Subclinical Atherosclerosis in Subjects with Coronary Artery Lesions After Kawasaki Disease

The objective of this study was to test the hypothesis that accelerated endothelial dysfunction and the development of premature atherosclerosis are associated with age in subjects with coronary artery lesions after Kawasaki disease (KD). A case-control study was performed at a university hospital that included 35 post-KD subjects across a wide age range (range, 8–42 years) without traditional cardiovascular risk factors and 35 age- and sex-matched healthy control subjects (Cont). Flow-mediated dilatation (FMD) of the brachial artery-induced by reactive hyperemia, intima media thickness (IMT), and elastic modulus (Ep) of the common carotid artery were compared between KD and Cont subjects assessed against age. KD subjects had slightly higher levels of body mass index, lipid profile, and HbA1c than Cont subjects, but the differences were not significant. The mean IMT (p < 0.001), age-adjusted percentage normal IMT (%N IMT; p < 0.0001), and Ep (p < 0.001) were significantly higher in KD than Cont subjects, and the peak FMD% (p < 0.01) was significantly lower in KD than Cont subjects. There were significant correlations between FMD% and age (r = −0.51 p < 0.0001), IMT and age (r = 0.68, p < 0.001), and Ep and age (r = 0.58, p < 0.01) in KD but not Cont subjects. When the difference in FMD% between KD and matched Cont subjects (ΔFMD%) was plotted against age, no significant relationship was found, although significant correlations between ΔIMT and age (r = 0.52, p < 0.01) as well as between ΔEp and age (r = 0.46, p < 0.05) were observed. When we defined values that were +2.0 SD over the mean control values (i.e., %N IMT ≥ 120% and/or Ep ≥ 50 kPa) as markers of subclinical atherosclerosis, 15 subjects met the criteria. Subjects over the age of 22 years were more likely to have (OR = 16.54, p = 0.0001) subclinical atherosclerosis in this cohort. Our results suggest that endothelial dysfunction and the development of premature atherosclerosis were accelerated in adult post-KD compared to Cont subjects.     

Acute Coronary Artery Dilation Due to Kawasaki Disease and Subsequent Late Calcification as Detected by Electron Beam Computed Tomography

We wanted to clarify the relationships between the degree of acute coronary artery dilation caused by Kawasaki disease and subsequent late calcification. Electron beam computed tomography (EBCT) was used to study 79 patients who had previously undergone selective coronary angiograms less than 100 days after the onset of Kawasaki disease. The EBCT was performed using an Imatron C-150 with a 100-ms exposure time and consecutive images at 6-mm intervals. The interval from the onset of Kawasaki disease to EBCT ranged from 2 to 242 months (median, 103 months). The maximum diameters of the right coronary, the left anterior descending, and the left circumflex arteries, as well as the bifurcation of the left coronary artery were measured in the initial coronary angiograms. A total of 250 branches, including 53 left coronary arteries, were measured, and the relationship between the degree of the initial coronary artery dilation and subsequent calcification in the branches and left coronary artery was analyzed. The coronary arterial diameter of all branches that eventually calcified was 6 mm or greater. The incidence of calcification in branches measuring 6 mm or greater on the initial coronary angiogram was 12% at 5 years, 44% at 10 years, and 94% at 20 years (n = 141). Dilation greater than 6 mm is associated with a high probability of late calcification.     

Pediatric Coronary Artery Revascularization Surgery: Development and Effects on Survival,Cardiac Events and Graft Patency for Children With Kawasaki Disease Coronary Involvements

Pediatric coronary artery bypass surgery gained wide acceptance with the introduction of internal thoracic arteries (ITAs) for bypass operations for post Kawasaki disease (KD) lesions. The technique is now established as the standard surgical choice, and its safety even in infancy, graft patency, growth potential, graft longevity and clinical efficacy have been well documented. In this article the author reviews the development of pediatric coronary bypass as the main indication for the treatment of coronary lesions due to KD. I believe that coronary revascularization surgery in pediatric population utilizing uni- or bilateral ITAs is the current gold-standard as the most reliable treatment, although percutaneous coronary intervention with or without a stent has been tried with vague long-term results in children.     

Percutaneous Transluminal Coronary Angioplasty for Coronary Arterial Stenosis in a 10-Year-Old Boy with Kawasaki Disease and a Brief Review

A 10-year-old boy developed coronary artery stenosis 9 years after suffering Kawasaki disease with coronary artery aneurysms at the age of 7 months old. Percutaneous transluminal coronary angioplasty was performed successfully to dilate the coronary arteries in order to prevent obstruction of the coronary arteries.     

川崎病患儿CD4+T淋巴细胞表面CD40L表达及其与冠状动脉损伤的关系

目的通过检测川崎病(KD)患儿静脉输注入血丙种球蛋白(丙球)治疗前后外周血T细胞表面CD40L(CD154)表达,探讨KD冠状动脉损伤的发病机制。方法采用流式细胞仪检测26例KD患儿静脉输注丙球治疗前后、16例其他发热性疾病患儿、15例正常儿童外局血T细胞表面的CD40L表达。采用酶联免疫吸附试验检测相应血清中E-选择素。结果KD患儿CD4 T细胞表面CD40L表达及血清E-选择素显著高于其他发热性疾病组及正常对照组(P<0.01),KD患儿静脉输注丙球治疗后明显下降(P<0.01)。CD4 T细胞表面CD40L表达及E-选择素与KD冠状动脉损伤有关,而CD8 T细胞表面CD40L的表达与冠状动脉损伤无关。KD患儿CD4 T细胞表面CD40L表达与E-选择素水平正相关(r=0.626P<0.05)。结论CD40L异常表达及血清E-选择素在KD发病机制中起重要作用。静脉输注丙球能下调CD40L表达及血清E-选择索,有利于血管炎治疗。     

川崎病患儿血清C反应蛋白、肿瘤坏死因子-α与心肌酶谱变化和冠状动脉损伤的关系

目的探讨川崎病(KD)患儿血清CRP、TNF-α与冠状动脉损伤及心肌酶谱变化的关系。方法选择确诊为KD患儿34例,其中20例无冠状动脉损伤,14例有冠状动脉损伤,按病程分为急性期、亚急性期和恢复期。另以年龄相仿的门诊体检健康儿童15例为健康对照组。应用免疫散射比浊法、双抗体夹心酶联免疫吸附法和全自动生化分析仪对各组进行血清CRP、TNF-α和心肌酶谱检测,并通过超声心动图检查患儿冠状动脉情况。结果KD患儿治疗前急性期血清CRP、TNF-α和CK-MB分别为(35.73±21.97)mg/L、(2.14±0.81)μg/L、(36.48±13.87)U/L,均显著高于健康对照组[(3.02±2.79)mg/L、(0.79±0.37)μg/L、(19.21±9.81)U/L](t=5.713,8.010,4.351 Pa<0.01);治疗后患儿上述指标分别为(6.05±4.99)mg/L、(0.83±0.65)μg/L、(21.42±11.51)U/L,基本恢复至正常水平。有冠状动脉损伤的KD患儿血清CRP、TNF-α水平分别为(46.29±30.43)mg/L和(2.88±0.53)μg/L,显著高于无冠状动脉损伤的患儿[(28.34±8.06)mg/L和(1.62±0.52)μg/L](t=2.904,6.904 Pa<0.05)。血清CRP、TNF-α水平与CK-MB水平均呈显著正相关(r=0.711,0.889 Pa<0.01)。结论KD患儿血清CRP、TNF-α的升高与患儿急性炎性反应程度密切相关,同时也可作为预测KD患儿心肌损伤及冠状动脉病变的重要参考指标。