Coronary revascularization in a child with Kawasaki disease: use of right gastroepiploic artery

In coronary insufficiency produced by Kawasaki disease, myocardial revascularization using saphenous vein, internal mammary arteries, and a combination of both grafts has been performed with considerable success. Recently, we successfully used a right gastroepiploic artery as another conduit in coronary revascularization of a 6-year-old boy with Kawasaki disease. Use of the gastroepiploic artery was feasible even in a small child, and this technique is expected to contribute to long-term graft patency as an arterial graft adjunct to internal mammary arteries.     

Treatment of a giant coronary artery aneurysm in an adult with a history of Kawasaki disease by resection and bypass grafting: Report of a case

We report herein the case of a 22-year-old man with a history of Kawasaki disease who developed a giant calcified aneurysm of the left main coronary artery. The aneurysm was successfully resected and coronary bypass surgery was performed using the bilateral internal thoracic arteries. The resected aneurysm, the maximal diameter of which was 27 mm, showed heavy calcification of the inner layer and extended into the adjacent coronary arteries, producing a significant narrowing of the lumen of both the left main trunk (50%) and the anterior descending branch (50%). Extensive intimal calcification presumably prevented normal luminal development and produced a significant narrowing as the patient grew into adulthood. A cause for stenotic lesions developing in the coronary artery adjacent to a coronary aneurysm in adults with a history of Kawasaki disease is suggested here by the resected aneurysm seen in this patient. Thus, adult patients with giant coronary artery aneurysms and significant stenotic lesions of the coronary artery associated with Kawasaki disease may require aneurysmectomy in addition to bypass surgery.     

冠状动脉旁路移植术治疗6例儿童川崎病并发冠状动脉病变

目的 总结冠状动脉旁路移植治疗儿童川崎病并发冠状动脉病变的近、中期疗效.方法 2005年2月至2009年9月,6例川崎病并发冠状动脉病变病儿接受冠状动脉旁路移植,其中男5例,女1例;年龄6～12岁.确诊川崎病0.5～5.0年.冠状动脉左主干闭塞1例,左、右冠状动脉瘤样病变5例.心功能(NYHA)分级Ⅱ级1例,Ⅲ级5例.术前心脏超声示左室舒张末内径(LVDD)39～54 mm;左室收缩未内径(LVSD)23～45 mm;左室射血分数(LVEF)0.33～0.71;二尖瓣中度反流1例.均在体外循环下手术,移植血管均用动脉,平均旁路移植血管(2.0±0.6)根.其中左乳内动脉4根,桡动脉7根.同期冠状动脉成形术4例,二尖瓣成形术1例.结果 无手术死亡,体外循环平均(95.6±31.0)min;主动脉阻断平均(57.8±33.9)min.术后LVDD 32～56 mm,LVSD 21～39 mm,LVEF 0.45～0.71.冠状动脉CT示移植血管均通畅.均获随访,无远期死亡,病儿生长发育同正常同龄儿.随访0.1～4.5年,心功能平均(1.4±0.55)级.5例术后1年移植血管100%通畅,1例术后2年移植血管通畅.结论 冠状动脉旁路移植术可以有效治疗川崎病并发冠状动脉病变,全动脉化有利于旁路血管远期通畅,其近、中期疗效满意.     

Coronary artery abnormalities in children with systemic-onset juvenile idiopathic arthritis

Still's disease (Systemic-onset Juvenile Idiopathic Arthritis: SoJIA) is characterised by high-spiking daily fevers, arthritis and evanescent rashes. Diagnosis of Still's disease is often challenging. Infectious diseases and other inflammatory conditions, especially in young children, Kawasaki disease may look similar. Clinicians often rely on echocardiographic evidence of coronary artery abnormalities to differentiate between Kawasaki disease and Still's disease. Coronary artery dilation would typically favour the diagnosis of Kawasaki disease. We present four children with Still's disease and coronary artery abnormalities who were initially misdiagnosed as Kawasaki disease. The first patient had pericarditis and an irregular wall of the left coronary artery, without dilation on echocardiography. The second patient had a left coronary artery dilatation and a pericarditis. The third patient had thickened left coronary artery walls, and the fourth patient had a hyperechogenicity of the left and right coronary arteries. They received IVIG without success. The diagnosis of Still's disease was made secondary with evidence of persistent arthritis. All but one patient finally needed biologic treatments. Coronary abnormalities may be observed during various febrile conditions and do not exclude the diagnosis of Still's disease.     

Review: surgical treatment of giant coronary aneurysms in pediatric patients with Kawasaki disease

In Kawasaki disease (KD), giant coronary aneurysms in the proximal segments of the coronary arteries have long been among the serious complications associated with acute myocardial infarction. To treat myocardial ischemia in children, Kitamura et al. first performed coronary artery bypass grafting in a pediatric patient using an autologous saphenous vein. In the early 1980s, they began to use the internal thoracic artery (ITA) as a bypass graft to the left anterior descending artery, which later was proven to improve long-term life expectancy with its favorable long-term patency, as well as growth potential. Thus, the excellent characteristics of the ITA have come to be widely known among pediatric cardiac surgeons, and a growing number of coronary bypass surgery procedures using the ITA are now being performed worldwide. Although a longer follow-up with more patients is necessary, downsizing reconstructive procedure may be a treatment of choice for giant aneurysms of non-LAD territories to improve coronary circulation. The efficacy of surgical treatment for giant coronary aneurysms in pediatric patients with Kawasaki disease is now well established. Pediatric coronary artery bypass grafting using the ITA, either single or bilateral, can be safe not only for patients with Kawasaki coronary disease but also for infants with congenital coronary lesions.     

Popliteal aneurysm presenting as acute thrombosis and ischemia in a middle-aged man with a history of Kawasaki disease

Kawasaki disease is known to cause a vasculitis of small and medium-sized vessels, with subsequent aneurysm formation. Most of the severe manifestations of the disease occur as a result of coronary aneurysm formation. However, many other arteries have been documented to be involved. A case is presented of a middle-aged man with a history of Kawasaki disease who had an acute ischemic limb from a thrombosed popliteal aneurysm that formed as a result of the disease. This is the first known case report of Kawasaki disease resulting in delayed lower extremity ischemia. Typical findings of patients with Kawasaki disease are presented, along with a case report and review of the literature. A history of Kawasaki disease is an extremely rare but possible cause of peripheral aneurysms, even in middle-aged patients. (J Vasc Surg 1997;26:884-7.)     

Atypical Kawasaki disease: A patient with coronary,brain, and internal mammary arteritis

Here we report a rare case of atypical Kawasaki disease (KD) in a patient presenting with systemic arteritis affecting the coronary arteries, brain, and internal mammary arteries (IMAs). A 25‐year‐old man was referred to our institute with angina pectoris. Coronary angiography revealed coronary artery aneurysms and triple‐vessel disease. Three‐dimensional brain computed tomography showed multiple small saccular aneurysms on the vertebral and posterior inferior cerebellar arteries. Off‐pump coronary artery bypass (OPCAB) grafting ??????was performed; however, the bilateral IMAs were tightly adhered and not patent. OPCAB was completed using the bilateral radial and gastroepiploic arteries. This is the first report of KD involving the IMA.     

Coronary artery bypass grafting in adult coronary artery disease due to suspected Kawasaki disease in childhood

Development of coronary artery aneurysms is one typical complication of Kawasaki disease and can cause coronary artery disease even in early childhood. Information about course and outcome in adults is rare. Here, we present a 49-year-old man with serious three-vessel coronary artery disease and giant coronary artery aneurysms following suspected Kawasaki disease.     

Coronary artery bypass grafting in an adult case with Kawasaki disease.

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease has been rarely reported in adult patients. We reported an adult case with few coronary risk factors but with multiple coronary artery aneurysms and obstructive lesions presumably secondary to Kawasaki disease who underwent coronary artery bypass grafting (CABG) with multiple arterial grafts. The postoperative course was uneventful. Because coronary artery sequelae of Kawasaki disease can be a cause of ischemic heart disease even in adults, heightened awareness of this possibility is required for young adults with coronary lesions but without coronary risk factors.     

Valvuloplasty for mitral regurgitation immediately following Kawasaki disease without abnormal coronary arteries lesion; report of a case

It is not uncommon that valve disease is complicated with Kawasaki disease (KD). However, it is rare to show normal coronary arteries simultaneously. We experienced a case of valvuloplasty towards the mitral regurgitation (MR) followed immediately after KD showing normal coronary arteries. A 3 year-old-female, with a diagnosis of KD at 4 months after birth, was referred to our hospital 5 months after birth. The echocardiography detected a moderate MR. The preoperative catheterization at 2.5 years old showed grade III MR, enlargement of left atrium and left ventricle, pulmonary capillary wedge pressure (PCWP) = 12 mmHg, left ventricular ejection fraction (LVEF) = 675, and normal coronary arteries. Pulmonary hypertention was not revealed. The operative findings showed mitral valve prolapse due to the elongation of the chordae of the anterior leaflet. She underwent artificial chordal reconstruction using expanded polytetrafluoroethylene sutures and mitral annuloplasty by Kay-Reed method. The postoperative course was uneventful, and she was discharged on postoperative day 19.     

Case report of CABG for progressive coronary artery stenosis after 22-year history of Kawasaki disease

More than 30 years has passed since Kawasaki disease was recognized as an independent disease entity, but the cardiovascular complications of Kawasaki disease are still not well known. We report an 22-year-old woman who underwent triple coronary artery bypass grafting because of a coronary artery aneurysm and multiple coronary artery stenoses, 22 years after the diagnosis of Kawasaki disease. A 2 cm coronary artery aneurysm due to Kawasaki disease was diagnosed when she was 10 years old, when she first presented with the symptom of dyspnea on effort. Since then, she was followed at the outpatient clinic. When she was 19 years old, the first coronary catheterization was performed. Two years later, the second coronary catheterization revealed progression of coronary artery disease. Therefore, coronary artery bypass grafting was performed. This case is rare from the point of view of long-term progression of coronary artery disease.     

Myocardial infarction in Kawasaki disease

A 5 1/2-month-old infant with Kawasaki disease complicated by coronary aneurysms is described. Despite myocardial infarction, the patient survived and is improving on medical management alone. Coronary aneurysms occur in 20% of cases presenting with Kawasaki disease. Medical management is aimed at preventing infarction and promoting healing of aneurysms. The use of anticoagulants and thrombolytics in Kawasaki disease is discussed.     

Surgical experience with coronary arterial sequelae of Kawasaki disease in children

The coronary arterial sequelae due to Kawasaki disease have been treated surgically in five children ranged from 6 to 9 years old. The procedures were aortocoronary bypass surgery in all cases, coronary artery aneurysmectomy in one case and left ventricular aneurysmectomy in one case. The early results of operated cases have been good with the graft patency of 86% confirmed by angiography one month after surgery. The characteristic features of coronary artery damage in patients with Kawasaki disease are coronary artery aneurysms, which manifest wall irregularity, thrombus, calcification and stenosis. The significant stenosis of coronary artery could often be observed at the inlet or outlet of the aneurysm in major coronary artery branches. Although the early results of aortocoronary bypass surgery in the children with Kawasaki disease have been good, long-term follow up is mandatory to investigate the status of autogenous saphenous vein grafted in children.     

Surgical treatment in an adult with coronary artery aneurysm at proximal site of left anterior descending artery; report of a case

A 52-year-old man was admitted to our hospital with complaint of chest pain and abnormal electrocardiogram (ECG) findings showing ST depression in V2-V6. Coronary computed tomography (CT) and coronary arteriography (CAG) showed coronary artery aneurysm at #5 [left main trunk (LMT)] 20 mm, #11 [circumflex artery (Cx)] 8.3 mm, RV branch 4 mm, and severe stenosis at #5 and #11. Therefore, his chest pain was due to thromboembolism from coronary artery aneurysm. In the present case, Kawasaki disease was not diagnosed in childhood. Coronary artery aneurysms were rare in the elderly and were usually found in association with Kawasaki disease. Morphological evaluation findings strongly suggested that the coronary artery aneurysm were related to Kawasaki disease. Resection of coronary artery aneurysm and coronary artery bypass grafting [left internal thoracic artery (LITA) to #8 and saphenous vein graft (SVG): aorta (Ao) to #14] were successfully performed. We report a case of coronary artery aneurysms presumed to be due to childhood Kawasaki disease in an elderly man.     

Symptomatic coronary obstruction due to Kawasaki disease in an adult

Kawasaki disease is the most common cause of pediatric ischemic heart disease in the world, but it is unusual in adults. We present a case of Kawasaki disease in a young adult. This 20-year-old man presented with angina. Coronary angiography revealed aneurysmal obstructive lesions consistent with remote Kawasaki disease. The patient underwent coronary artery bypass grafting with arterial conduits. Postoperative echocardiography was normal and stress myocardial perfusion imaging showed no ischemia. He remained asymptomatic 12 months after surgery. There is controversy regarding optimal therapy, choice of conduit, treatment of proximal aneurysms, and surveillance in adults with Kawasaki disease.     

Minimally invasive coronary artery bypass grafting surgery in a child with Kawasaki disease

An 8-year-old girl with Kawasaki disease underwent surgical revascularization to the left anterior descending coronary artery on the beating heart via a left anterior short thoracotomy. Angiography 21 months after surgery showed excellent graft patency. This case--the first success in minimally invasive surgical coronary artery revascularization in a child in the world--suggests that minimally invasive methods are a reasonable alternative in coronary artery revascularization in a child with Kawasaki disease whose left anterior descending artery is the only requiring it.     

Coronary artery bypass grafting for coronary aneurysms due to Kawasaki disease.

We report a 23-year-old man who underwent coronary artery bypass grafting (CABG) for coronary aneurysms associated with Kawasaki disease using the left internal thoracic artery (LITA) and right gastroepiploic artery (RGEA) after a second myocardial infarction (MI). Preoperatively, this patient showed repetitive occlusion and recanalization of coronary artery flow without coronary stenosis. Indication of bypass surgery in Kawasaki disease is usually associated with stenosis. However, even an aneurysm alone should be an indication of surgery if there is any kind of ischemic event.     

Kawasaki disease: basic and pathological findings

Kawasaki disease (KD) is considered to be a kind of systemic vasculitis syndrome. It most frequently affects infants and young children and primarily invades medium-sized muscular arteries, including the coronary arteries. The etiology of KD is unknown, but epidemiological data suggest involvement of infectious agents, such as bacteria and viruses, in the onset of KD. In addition, host genetics underlie the disease’s pathogenesis. Histologically, coronary arteritis begins 6–8 days after KD onset, and inflammation of all layers of the artery rapidly ensues. The inflammation spreads completely around the artery, resulting in severe damage to structural components. Then, the artery begins to dilate. KD arteritis is characterized by inflammation consisting of marked accumulation of monocytes/macrophages. Aberrant activation of monocytes/macrophages is thought to be involved in the formation of vascular lesions. Inflammatory-cell infiltration persists until about the 25th day of the disease, after which the inflammatory cells gradually decrease in number. Lesions in all arteries are relatively synchronous, as they evolve from acute to chronic injury. If a giant aneurysm remains or vessel recanalization occurs after thrombotic occlusion of an aneurysm, remodeling of the vascular structure, sometimes including even reocclusion, continues even in the remote stage.     

Ischemic small bowel strictures in a case of incomplete Kawasaki disease

The authors describe an atypical case of Kawasaki disease in a 9-month-old girl who presented with fever, coronary artery aneurysms, and acquired ischemic stricture of the proximal jejunum. Histology of the surgical specimen was consistent with mesenteric vasculitis. The infant had only some of the typical clinical signs of Kawasaki disease, suggesting that an atypical or incomplete form of the disease was present. To the best of the authors' knowledge this is only the third case to be reported of incomplete Kawasaki disease associated with ischemic bowel stricture. J Pediatr Surg 36:648-650.     

Severe Kawasaki heart disease treated with an internal mammary artery graft in pediatric patients. A first successful report

Two Japanese boys, 6 and 10 years old, required operation for severe Kawasaki heart disease. Both had multiple coronary arterial aneurysms and stenoses, and one had mitral regurgitation as well. The operations consisted of anastomosis between the left internal mammary artery and the left anterior descending artery and insertion of an autologous saphenous vein between the aorta and the posterior descending artery in both patients. The mitral valve was replaced in the one with mitral regurgitation. Angina pectoris has been completely relieved as confirmed by postoperative angiocardiography. Late results of coronary bypass grafting with the saphenous vein in pediatric patients with Kawasaki disease have been less than satisfactory because of the high occlusion rate of the graft. The internal mammary artery may be superior, at least theoretically, to the saphenous vein graft because it is a "living graft" with a high possibility of growing and with less susceptibility to degeneration. This is the first report of successful operation utilizing an internal mammary artery graft in coronary bypass for Kawasaki disease.