Akimoto Katsumi, Harada Mana, Oda Hisayuki, Furukawa Takeshi, Takahashi Ken, Kishiro Masahiko, Shimizu Toshiaki, Nakanishi Keisuke, Kawasaki Shiori, Amano Atsushi
Pediatrics and Adolescent Medicine Department, The Juntendo University, Tokyo, Japan.
Cardiovascular Surgery Department, The Juntendo University, Tokyo, Japan.
Front Pediatr. 2020 Sep 18;8:547369. doi: 10.3389/fped.2020.547369. eCollection 2020.
In recent years, >100 cases of coronary artery stenotic lesions due to Kawasaki disease were treated with coronary artery bypass grafting (CABG). Surgical indications include stenosis of >75%, myocardial infarction history, electrocardiographic changes, and ischemia, as detected by myocardial scintigraphy and electrocardiography, due to drugs or exercise. Some centers have reported good patency rates, even in infants. The advantages of CABG in younger patients are minimal loss of left ventricular function, early elimination of post-operative ischemia risk, and improved quality of life. However, the disadvantage of performing CABG in younger patients is the small coronary artery diameter and the thin vessel wall, which can lead to post-operative occlusion, especially when performed by inexperienced surgeons. The optimal timing of CABG varies by institution and case, which depends on the presence or absence of complications, such as left ventricular dysfunction or valve regurgitation, and surgeon's experience. Importantly, unlike adult surgery, childhood CABG needs to be kept open for the very longest possible period of time to determine the optimal conditions for surgery. We report two pediatric cases of giant coronary artery aneurysms diagnosed in infancy. During school age, the patients had a mild decline of left ventricular ejection function. In one case, there were no clinical symptoms because of the development of collateral vessels and limitation of exercise. Both patients underwent surgery with good results. The gastric gastroepiploic artery could be anastomosed owing to the development of collateral blood vessels, although it was obstructed. At 1 year after surgery, both patients had a good post-operative course without complications of anastomotic stenosis or myocardial damage due to aneurysm resection. If conditions are favorable, bypass surgery can be postponed to several years until the coronary arteries are sufficiently large to warrant a delay in coronary artery stenosis in cases of infantile Kawasaki disease.
近年来，超过100例川崎病所致冠状动脉狭窄性病变患者接受了冠状动脉旁路移植术（CABG）。手术指征包括狭窄超过75%、有心肌梗死病史、心电图改变以及心肌闪烁显像和心电图检测显示因药物或运动导致的缺血。一些中心报告称，即使是婴儿患者，血管通畅率也很高。CABG对年轻患者的益处包括左心室功能损失最小、术后早期消除缺血风险以及提高生活质量。然而，年轻患者进行CABG的缺点是冠状动脉直径小且血管壁薄，这可能导致术后闭塞，尤其是由经验不足的外科医生进行手术时。CABG的最佳时机因机构和病例而异，这取决于是否存在并发症，如左心室功能障碍或瓣膜反流，以及外科医生的经验。重要的是，与成人手术不同，儿童CABG需要尽可能长时间保持开放状态，以确定最佳手术条件。我们报告两例婴儿期诊断为巨大冠状动脉瘤的儿科病例。在学龄期，患者左心室射血功能轻度下降。其中一例因侧支血管形成和运动受限而无临床症状。两名患者均接受了手术，效果良好。尽管胃网膜动脉受阻，但由于侧支血管形成，仍可进行吻合。术后1年，两名患者术后病程良好，无吻合口狭窄或动脉瘤切除导致心肌损伤的并发症。如果条件允许，旁路手术可推迟数年，直到冠状动脉足够粗大，对于婴儿期川崎病病例可推迟冠状动脉狭窄的发生。
