川崎病并发严重冠状动脉病变患儿旁路移植术术前评估及术后随访

目的回顾性总结川崎病(KD)并发严重冠状动脉病变患儿的影像学诊断、冠状动脉旁路移植术结果及随访情况。方法复旦大学附属儿科医院2006年8月至2008年3月收治5例(男3例,女2例)KD并发严重冠状动脉病变患儿,年龄12个月至10岁4个月。所有患儿均在KD急性期予IVIG治疗,其中3例予2次。病程第15～21天均行超声心动图(ECHO)检查发现冠状动脉病变;之后常规随访ECG和ECHO,并口服阿司匹林和双嘧达莫或氯吡格雷。1例患儿行64排螺旋CT(MSCT)检查,2例行99Tcm-MIBI心肌灌注显像检查。在病程6～65个月行选择性冠状动脉造影检查,并行冠状动脉旁路移植术及冠状动脉成形术。结果 1/5例在病程中有心绞痛发作,3/5例有心功能不全,1/5例无症状。1/5例有心肌梗死发生并在恢复过程有ECG记录;2/5例ECG有ST-T改变;2/5例ECG未见异常。ECHO除均显示多发性冠状动脉瘤(CAA)外,3/5例还显示左心房和左心室增大,左室射血分数(LVEF)和短轴缩短率的降低,2/5例左室壁运动不协调,与99Tcm-MIBI检查结果一致。冠状动脉造影均可见多发性CAA且至少一处为中等或巨大CAA,并伴有血栓形成和远端闭塞。MSCT与冠状动脉造影检查结果一致。年龄最小的1例患儿(手术时22个月)在冠状动脉移植术中死亡,其余4例术后即刻效果满意。在8～24个月的随访中,1例LVEF较低,随访1年未达到正常;1例术后18个月复发KD,治疗顺利,复查ECHO和MSCT未见冠状动脉进一步损害。4例患儿目前仍在随访中。结论 KD并发冠状动脉病变应定期随访ECG、ECHO,必要时进行99Tcm-MIBI和MSCT检查;如考虑手术需行冠状动脉造影仔细评估冠状动脉病变部位和程度。有心肌缺血表现需及时行冠状动脉旁路移植术和冠状动脉成形术,手术的近期效果显著,远期疗效有待长期随访结果。

The evaluation and medium-term follow-up of coronary artery bypass grafting in Kawasaki disease children with severe coronary artery lesions

Objective Kawasaki disease (KD) has become the most common cause of acquired cardiovascular disease in children. Children with severe coronary artery lesions (CALs) usually need further assessment and coronary artery bypass grafting. Methods Five cases were recruited, including 3 boys and 2 girls, aged from 12month to 10 years and 4 months. Intravenous gammaglobulin (IVIG) was given in all cases, and second dose IVIG in 3 cases. CALs were found by echocardiography (ECHO) from day 15 to day 21 of the course. All patients were followed up with ECHO and ECG regularly, moreover, multislice computed tomography (MSCT) was performed in 2 patients and 99Tcm-MIBI performed in 2 patients. Coronary artery angiography was performed 6 months to 65 months after diagnosis of KD, and all the five patients underwent coronary artery bypass grafting (CABG) and giant coronary aneurysm size-reducing repair. Results Among 5 patients, 1 had angina and 3 had heart failure, the remaining one with asymptomatic. One patient had documented myocardial infarction ECG and recovered to normal gradually, 2 patients had ST-T changes in ECG, and the other 2 patients had normal ECG. In addition to multiple coronary aneurysms, ECHO also showed enlargement of left atrium and left ventricle with low ejection fraction (LVEF) and shortening fraction (LVFS) in 3 patients, and ventricular wall movement disconcordance in 2 patients who also had multiple ischemic focuses in 99Tcm-MIBI. Coronary angiogram showed more than one coronary aneurysm formation and at least one giant aneurysm found in all patients, thrombogenesis and distal coronary artery blocked in all the 5 patients. MSCT findings were exactly the same as the angiogram. Four patients had satisfactory immediate results after coronary artery bypass grafting. However, the youngest patient (22-month-old) died during the operation. During follow-up, LVEF was gradually improved, but not reached normal. One boy recurred 18 months after operation, with no aggravation in coronary artery. Conclusions CALs should be followed up in patients with KD regularly. ECG, ECHO and 99Tcm-MIBI and even MSCT should be combined for examination in those severe cases if available. CABG should be considered when myocardial ischemia was detected, and coronary artery angiogram was necessary before CABG operation.