Presumed Kawasaki disease resulting in multiple coronary artery aneurysms in an adult

Kawasaki disease (mucocutaneous lymph node syndrome) is a pathological process seen mostly in children, but has been reported in adults. The late manifestations of the syndrome can include the development of multiple coronary artery aneurysms. This article describes a 27-year-old man with no risk factors for atherosclerotic disease with multiple coronary artery aneurysms.     

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.     

Coronary bypass in an adult with Kawasaki disease

We present the case of a 30-year-old female patient with few coronary risk factors for atherosclerosis but with 3-vessel coronary artery disease possibly secondary to Kawasaki disease. Coronary angiography showed total occlusion of the left anterior descending artery and a right coronary artery aneurysm. Quadruple coronary artery bypass was performed. The postoperative course was uneventful.     

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.     

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.     

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.     

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.     

Multiple aneurysms of the coronary arteries in a patient with systemic aneurysmal disease

A case of multiple coronary artery aneurysms in a patient with an abdominal aortic aneurysm and bilateral popliteal artery aneurysms is reported. As diagnosis and treatment of coronary artery disease become more aggressive, a higher incidence of detection of coronary artery aneurysms in conjunction with peripheral vascular lesions is likely. The role of coronary sinus cardioplegia in minimizing the risk of embolization from the coronary aneurysms during surgical repair is emphasized.     

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.     

Staged coronary artery bypass grafting after percutaneous angioplasty for intracranial vascular stenosis

OBJECTIVE: Cerebrovascular disease is commonly associated with coronary artery disease and is a major risk factor for cardiac surgery. Concomitant coronary artery bypass grafting and carotid endarterectomy may reduce the risk of stroke; however, this staged operation is effective only for extracranial lesions. The strategy for on-pump coronary artery bypass grafting for patients with intracranial vascular stenosis is still controversial. METHODS: The subjects were 157 consecutive candidates for coronary artery bypass grafting who underwent computed tomography and digital subtraction cerebral angiography preoperatively to check for cerebrovascular disease. Additional single-photon emission computed tomography was performed to evaluate cerebral ischemia, according to the neurologist's request. Patients with diffuse intracranial vascular stenosis impossible to treat with percutaneous transluminal angioplasty underwent off-pump coronary artery bypass grafting. Patients with a circumflex coronary artery lesion first underwent percutaneous transluminal angioplasty for cerebral vascular stenosis followed by secondary on-pump coronary artery bypass grafting. RESULTS: Three patients were selected for staged operations. Percutaneous transluminal angioplasty was performed for 4 intracranial stenotic lesions. All lesions were dilated successfully, and no complications developed during or after the procedure. All patients tolerated staged coronary artery bypass grafting and were extubated within 1 day without any mental disturbance. No further neurologic complication occurred, and computed tomography performed postoperatively revealed no significant changes. CONCLUSION: Staged on-pump coronary bypass after percutaneous transluminal angioplasty for cerebrovascular disease may reduce the risk of stroke during cardiopulmonary bypass, and it is useful especially in patients with intracranial cerebrovascular disease.     

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.     

Anomalous origin of the left coronary artery from the pulmonary artery with coronary artery steal in adults. Report of two cases and review of the literature.

Patients with anomalous left coronary artery arising from the pulmonary artery rarely survive to adult life. Those who attain adulthood may present with angina indistinguishable from coronary artery disease and are liable to sudden death. Myocardial infarction, though rare in young adults, may occur and may be due to coronary artery steal. Accurate diagnosis requires coronary arteriography. Two further cases of coronary artery steal in adults with anomalous origin of the left coronary artery from the pulmonary artery are presented. In both patients aortocoronary bypass grafting using a reversed autogenous saphenous vein with closure of the origin of the anomalous left coronary artery was successfully performed. This operation provided complete symptomatic relief and may protect patients against the risk of sudden death.     

Bland-White-Garland syndrome in pregnancy: reoperation of ALCAPA with an internal thoracic radial artery "Y"-graft

Anomalous origin of the left coronary artery from the pulmonary artery is rare and more so in the adult. Reimplantation of the left main coronary into the aorta is successful in early life, but it may be more difficult in the adult who had a previous repair. We report a successful reoperation of anomalous origin of the left coronary artery from the pulmonary artery in an adult patient using a left internal thoracic and radial artery "Y"-graft. Composite arterial grafting has become an established and straight forward technique in coronary surgery, and it is appropriate and recommended for congenital lesions in adults and at any age if necessary.     

Early Subclinical Coronary Artery Calcification in Young Adults Who Were Pediatric Kidney Transplant Recipients

Coronary artery disease (CAD) is the leading cause of death in adults after successful kidney transplantation. Children who have undergone successful kidney transplantation are entering young adulthood; however, the prevalence and extent of CAD in this population is unknown. We conducted a pilot study in young adults with stable allograft function, who received kidney transplants as children to measure coronary artery calcification (CAC), a marker of coronary artery atherosclerosis and CAD. We evaluated 19 young adults after successful pediatric kidney transplantation for known CAD risk factors; these patients underwent noninvasive imaging with electron-beam computed tomography (EBCT) for measurement of CAC. Prevalence and quantity of CAC were then compared to asymptomatic individuals from the community. All patients had multiple risk factors for CAD. Mean age at evaluation was 32 years (range: 21-48 years). CAC is uncommon in individuals in the community in this age range; however, nearly half of our patients had CAC detected with the quantity of CAC comparable to asymptomatic individuals from the community 10-40 years older. These data suggest young adults who received pediatric kidney transplants are at increased risk for developing early CAC and need close monitoring to detect early CAD so as to prevent premature cardiac morbidity and mortality.     

Cardiovascular changes during chronic hypertensive states

It is well established that elevated blood pressure constitutes a major risk factor for coronary heart disease, arrythmias, heart failure, cerebrovascular disease, peripheral artery disease and renal failure. Blood pressure level and the duration of arterial hypertension (HTN) impact target organ damage. Many studies in adults have demonstrated the role of antihypertensive therapy in preventing cardiovascular (CV) events. The so-called hard end-points, such as death, myocardial infarction (MI) or stroke, are rarely seen in children, but intermediate target organ damage, including left ventricular hypertrophy, increased intima-media thickness and microalbuminuria, is already detectable during childhood. The goal of antihypertensive treatment is to reduce the global risk of CV events. In the adult population stratification of CV risk is based on blood pressure level, risk factors, subclinical target organ damage and established CV and kidney disease. Increased CV risk begins early in the course of kidney disease, and CV diseases are the most frequent cause of morbidity and mortality in patients with chronic kidney disease (CKD). Children with CKD are especially prone to the long-term effects of CV risk factors, which result in high morbidity and mortality in young adults. To improve the outcome, pediatric and adult CKD patients require nephro- and cardioprotection.     

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.     

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.     

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.     

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.