Long-term follow-up of patients with Kawasaki disease

Abstract

Cardiac sequelae of Kawasaki syndrome may range from no detectable' abnormalities to giant aneurysms with thrombosis or stenosis. The issues often debated in long-term follow-up include interval and intensity of evaluations, type of diagnostic tests to be used, choice of drugs and indications for medical and surgical interventions directed toward coronary artery problems. Although echocardiography is a powerful tool in the early follow-up, its utility is diminished during the chronic phase. Although the value of coronary angiography is undisputed, its use should be limited to the patients with large or complex aneurysms. Repeat angiography should be guided for the most part by appearance or worsening of ischemic changes by non-invasive studies. Despite normal angiographic appearance of the coronary artery following regression, recent evidences from vasoactivity studies, intravascular ultrasound, and biochemical data suggest long-term abnormalities in vascular endothelium. Stress ECG lacks in sensitivity and specificity. Stress echocardiography with exercise or dobutamine may be an acceptable alternative, but its performance is subject to the ‘learning curve.’ Myocardial scintigraphy has been shown to be sensitive in detecting ischemia. However, its specificity in Kawasaki syndrome is still debatable. Recent ‘high-tech’ diagnostic tests have limitations in clinical applicability. Regarding therapy, our midterm experience with the combined use of low-dose warfarin and low-dose aspirin in patients with giant aneurysms suggests its efficacy in preventing coronary thrombosis. Thrombolytic therapy for acute infarction or coronary thrombosis appears safe and effective. The role of coronary balloon angioplasty in the management of Kawasaki syndrome is uncertain. Controversies surround the indications for coronary artery bypass graft surgery in Kawasaki syndrome. Decision for surgery seems justified in an asymptomatic child when evidence points to a large myocardial segment in jeopardy since a high mortality rate and lack of prior warning are characteristic of myocardial infarction due to Kawasaki disease.