To the Editor: Atherosclerosis is a well-known cause of coronary artery disease (CAD). Risk factors, including hypertension, hyperlipidemia and hyperglycemia, are well established. Kawasaki disease is a risk factor for the development of coronary artery aneurysm and stenosis in most infants and children but surgical revascularization for coronary artery lesions caused by Kawasaki disease has been rarely reported in adult patients. Kawasaki disease plays an important role in ischemic heart disease in adults without coronary risk factors. We encountered a young adult male with Kawasaki disease who underwent off-pump beating coronary artery bypass grafting (OPB-CABG).
A 35-year-old man with a history of mucocutaneous lymph node syndrome (Kawasaki disease) in childhood presented with chest tightness accompanied with shortness of breath for 6 months. He had no family history of atherosclerotic disease or associated risk factors such as smoking, hypertension and hyperlipidemia. There were no abnormalities in the physical examination or laboratory data. An electrocardiogram showed ST-segment depression and T wave inversion in leads V5 and V6. Treadmill-exercise testing revealed a high probability of CAD. The transthoracic echocardiography showed hypokinesia to akinesia of the proximal inferior wall and an estimated ejection fraction of 43%. Coronary angiography showed ectasis of the left main and diffuse ectasia of the left anterior descending artery (LADA) with proximal to distal diffuse segmental eccentric stenosis estimated to be about 50% to 60%. Angiography also showed a 95% discrete eccentric stenosis at the ostium of the first diagonal branch (Figures 1, 2) and diffuse ectasia at the proximal portion of the circumflex coronary artery with total occlusion at the middle portion (Figure 3) and diffuse ectasia at the proximal portion of the right coronary artery with total occlusion at the middle portion (Figure 4). CAD with a three-vessel aneurysm component was diagnosed, which is the appearance typically seen in Kawasaki disease. Percutaneous transluminal coronary angioplasty (PTCA) failed for the right coronary artery and left circumflex artery lesions. The patient underwent surgical revascularization by OPB-CABG with four-vessels grafts: left internal mammary artery to LADA, greater saphenous grafting vein to the secondary diagonal branch, distal left circumflex coronary artery, and secondary obtuse marginal. The postoperative course was uneventful and he had no further cardiac events at 2 years follow-up.
Figure 1.
Coronary angiography showing severe coronary artery disease with several aneurysms and stenoses (arrow).
Figure 2.
Aneurysmal left anterior descending artery and 95% ostium stenosis of the first diagonal branch.
Figure 3.
Proximal ectasia and total occlusion of the middle portion of the circumflex coronary artery (arrow).
Figure 4.
Proximal ectasia and total occlusion of the middle portion of the right coronary artery (arrow).
Kawasaki disease is a syndrome that involves the skin, mouth, and lymph nodes. The outcome varies from complete recovery to fatal complications of coronary artery involvement. 1 Development of aneurysms and occlusive lesions in Kawasaki disease, particularly in children, have been well documented.2 By spontaneous regression of coronary complications in Kawasaki disease, adult ischemic heart disease secondary to Kawasaki disease is uncommon. In adults, CAD is usually related to multiple predisposing factors, such as hyperlipidemia, cigarette smoking, diabetes mellitus, hypertension, strong family history, and others. However, in the absence of such risk factors, Kawasaki disease should be considered a cause of coronary artery lesions. In pediatric Kawasaki disease patients with coronary artery occlusive disease, anti-angina drugs and coronary angioplasty are often used as effective treatment.3 For PTCA failure or multiple coronary artery stenosis cases, CABG using arterial grafts can provide good results in long-term clinical follow-up.4 Kato reported 9 of 21 adult patients with a definite or suspected history of Kawasaki disease who underwent CABG and there are other case reports.5–8 In a review, clinical symptoms were described as acute myocardial infarction (MI) or previous MI or angina pectoris and the patients received conservative medical treatment, angioplasty, or surgical intervention in the form of CABG.9 Good results were reported for the CABG group while medication or PTCA has failed. Thus, CABG may be preferable in adult patients with Kawasaki disease as well as in adults with atherosclerotic ischemic heart disease. OPB-CABG is as effective as traditional CABG in the CAD patient.10 We adopted the off-pump beating technique for multiple arterial grafts and successfully treated our CAD adult patient with Kawasaki disease. Long-term follow-up is necessary to compare the new technique and traditional CABG.
REFERENCES
- 1.Gupta-Malhotra M, Rao PS. Current perspectives on Kawasaki disease. Indian J Pediatr. 72:621–629. doi: 10.1007/BF02724189. 205. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kato H, Ichinose E, Yoshioka F, Takechi T, Matsunaga S, Suzuki K, et al. Fate of coronary aneurysms in Kawasaki disease: serial coronary angiography and long-term follow-up study. Am J Cardiol. 1982;49:1758–1766. doi: 10.1016/0002-9149(82)90256-9. [DOI] [PubMed] [Google Scholar]
- 3.Ino T, Akimoto K, Ohkubo M, Nishimoto K, Yabuta K, Takaya J, et al. Application of Percutaneous transluminal coronary angioplasty to coronary arterial stenosis in Kawasaki disease. Circulation. 1996;93:1709–1715. doi: 10.1161/01.cir.93.9.1709. [DOI] [PubMed] [Google Scholar]
- 4.Yoshikawa Y, Yagihara T, Kameda Y, Taniguchi S, Tsuda E, Kawahira Y, et al. Result of surgical treatments in patients with coronary-arterial obstructive disease after Kawasaki disease. Eur J Cardiothorac Surg. 2000;17:515–519. doi: 10.1016/s1010-7940(00)00355-9. [DOI] [PubMed] [Google Scholar]
- 5.Kato H, Inoue O, Kawasaki T, Fujiwara H, Watanabe T, Toshima H. Adult coronary artery disease probably due to childhood Kawasaki disease. Lancet. 1992;340:1127–1129. doi: 10.1016/0140-6736(92)93152-d. [DOI] [PubMed] [Google Scholar]
- 6.Ishiwata S, Fuse K, Nishiyama S, Nakanishi S, Watanabe Y, Seki A. Adult coronary artery disease secondary to Kawasaki disease in childhood. Am J Cardiol. 1992;69:692–694. doi: 10.1016/0002-9149(92)90168-x. [DOI] [PubMed] [Google Scholar]
- 7.Sato T, Isomura T, Hayashida N, Aoyagi S. Coronary artery revascularization in an adult with coronary aneurysms probably secondary to childhood Kawasaki disease. Eur J Cardio-thorac Surg. 1997;12:312–314. doi: 10.1016/s1010-7940(97)01199-8. [DOI] [PubMed] [Google Scholar]
- 8.Bey M, Chenik S, Thameur H, Baccar H, Belhani A. Coronary bypass in an adult with Kawasaki disease. Heart Surg Forum. 2004;7:E128–129. doi: 10.1532/HSF98.200344703. [DOI] [PubMed] [Google Scholar]
- 9.Garcia-Moll X, Bardaji A, Alonso J, Bueno H. Ischemic heart disease: 2006 update. Rev Esp Cardiol. 2007;60(Suppl 1):3–18. doi: 10.1157/13099709. [DOI] [PubMed] [Google Scholar]
- 10.Murphy GJ, Ascione R, Angelini GD. Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade? Eur Heart J. 2004;25:2077–2085. doi: 10.1016/j.ehj.2004.09.022. [DOI] [PubMed] [Google Scholar]