Pediatric Coronary Artery Bypass Research Articles

Bilateral internal thoracic artery grafting in children under 5 years of age with Kawasaki disease: a case series.

BackgroundAlthough persistent coronary artery aneurysm of Kawasaki disease (KD) is rare, some patients develop a life-threatening myocardial infarction. In paediatric coronary artery bypass surgery (PCABS), the internal thoracic artery (ITA) graft is a reliable graft with favourable coronary outcomes. However, few studies have reported the outcomes and technical considerations of PCABS using bilateral ITAs in small children who have multivessel disease.Case summaryWe present the cases of three children under 5 years of age who underwent PCABS utilizing bilateral ITAs. All three patients had known bilateral giant coronary aneurysms associated with KD. Paediatric coronary artery bypass surgery was indicated after confirming multiple coronary lesions with myocardial ischaemia. One child underwent emergency PCABS because of circulatory collapse. The arterial anastomoses were performed under cardioplegic arrest. The left ITA was anastomosed to the left anterior descending artery (LAD) or the circumflex artery. The right ITA was anastomosed to the right coronary artery or the LAD. Post-operative coronary angiography revealed patent bilateral ITA grafts with an excellent run-off in all patients, and none of them have suffered any subsequent coronary event.DiscussionBilateral ITA grafting is a feasible procedure with favourable coronary outcomes for treating small children with multivessel disease, even in the setting of circulatory collapse.

State-of-the-Art Pediatric Coronary Artery Bypass Surgery: a Literature Review.

ObjectiveTo examine the results of various myocardial revascularization techniques in pediatric patients to better understand the strategies for surgical treatment of coronary artery pathologies.MethodsWe analyzed 61 publications dedicated to the indications, methods, and results of coronary bypass surgery in children. Due to the small size of this cohort, case reports are also included in our review.ResultsThe main indications for coronary bypass grafting in children are Kawasaki disease, myocardial revascularization as a necessary procedure during the congenital cardiac surgery, to manage intraoperative iatrogenic damage to coronary arteries, and homozygous familial hypercholesterolemia. The use of internal thoracic arteries as conduits for coronary bypass grafting in children with Kawasaki disease showed significantly better results in long-term functionality compared to autovenous conduits (87% and 44%, respectively, P<0.001). Acute and late coronary events after arterial switch operation for the transposition of the great arteries, anomalous origin of the left coronary artery from the pulmonary artery, and left main coronary artery atresia are the main congenital heart diseases where surgical correction involves interventions on the coronary arteries.ConclusionThe internal thoracic artery is a reliable and durable conduit that demonstrates proven growth potential in children.

Pediatric coronary artery surgery. A new area in cardiac surgery?

Introduction and aim: Pediatric coronary artery surgery for congenital heart disease has become increasingly important in newborns and infants. It is life-saving in unsuccessful coronary transfer surgery, injury of coronary artery during surgery, in pediatric coronary artery bypass surgery (PCABS) due to acquired Kawasaki disease. Method: We review the current surgical role of congenital and acquired coronary artery diseases in newborns and infants. Results: The 7 main challenges are: 1) anomalous origin of the left coronary artery from the pulmonary artery; 2) different variations of the origins of the coronary arteries in transposition of the great arteries (TGA); 3) acute and late coronary events in the arterial switch operation for TGA; 4) complications after coronary transfer procedures: Ross-, Nikaidoh operation; 5) inadvertent coronary artery injury during heart surgery; 6) Kawasaki disease; 7) coronary artery procedures in premature infants. Direct coronary reimplantation in most, surgical angioplastic procedures in selected patients is the first choice; however, PCABS with internal thoracic artery (ITA) grafts can be life-saving in emergency or severe myocardial hypoperfusion conditions. Since the patency of saphenous vein grafts is poorer than that of ITA grafts, their use should be avoided in growing children. The procedures can be performed safely in neonates and infants, using high-power magnifying glasses or a surgical microscope. Conclusion: Pediatric coronary artery surgery technique is now established as the standard safety surgical choice, as a new area in cardiac surgery. Congenital heart surgeons after proper training are able to use coronary transfer and bypass surgery safely even in premature babies. Orv Hetil. 2019; 160(49): 1935-1940.

Outcomes following coronary artery bypass grafting with microsurgery in paediatric patients.

Paediatric coronary artery bypass grafting is indicated in cases of clinically significant and symptomatic coronary stenosis, with frequent complications occurring in the perioperative period. To reduce complications and improve outcomes of these procedures, surgical microscopes have been used at our centre with the anastomosis performed by a microvascular surgeon. The purpose of this article is to report our institutional experience in all patients who have undergone paediatric coronary artery bypass grafting procedures with and without microvascular techniques. Twenty-four patients who underwent coronary artery bypass grafting from January 2000 to May 2017 were retrospectively reviewed. Eighteen patients underwent bypass without microvascular involvement and 6 patients required the use of microsurgical techniques. Median age at the time of operation was 9.79 and 2.02 years for the 2 groups, respectively. The median weight at the time of operation was 41.2 and 10.75 kg for the 2 groups, respectively. Procedures were performed emergently in 4 patients. Three major anastomotic complications occurred requiring reoperation, although none occurred in the microvascular group. The median follow-up was 3.40 years and 5.25 years for the 2 groups, respectively. Three patients were symptomatic at last follow-up and 2 deaths occurred, all in the non-microvascular group. All grafts were patent in both groups. There were no statistically significant differences between preoperative and postoperative ejection fraction between the groups. Our results highlight the potential positive impact of collaboration between cardiac and microvascular surgeons during paediatric coronary artery bypass grafting procedures and the subsequent reduction in complications that may be expected.

A new arena in cardiac surgery: Pediatric coronary artery bypass surgery.

Prior to the 1970s, pediatric coronary artery bypass surgery (PCABS) was seldomly performed due to the lack of compelling surgical indications. The advent of coronary sequelae secondary to Kawasaki disease (KD) and the occurrence of coronary artery complications due to newly developed procedures, such as the arterial switch operation and early repair for intrinsic congenital coronary malformations, necessitated the development of PCABS. Because children grow rapidly and their life expectancy is very long, with increasing exercise capability requirements, the strategy for PCABS should differ from that for bypass surgery in adults. PCABS utilizing unilateral and bilateral internal thoracic arteries (ITA) has become the most reliable surgical method for children because of the distinct structure of ITAs being resistant to KD, growth potential according to the child’s somatic growth and long-term patency without wall degeneration. This operation utilizing ITA grafts is now being performed worldwide and is referred to as the “Kitamura operation” for KD coronary sequelae. Notably, the use of vein grafts should be avoided in children. Likewise, this operation can now be successfully performed in infants using a surgical microscope, for congenital coronary disorders. Currently, PCABS with ITAs has been established as a new arena in cardiac surgery, following our initial attempts.

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.

Pediatric Coronary Artery Revascularization Surgery: Development and Effects on Survival, Cardiac Events and Graft Patency for Children With Kawasaki Disease Coronary Involvements.

Pediatric coronary artery bypass surgery gained wide acceptance with the introduction of internal thoracic arteries (ITAs) for bypass operations for post Kawasaki disease (KD) lesions. The technique is now established as the standard surgical choice, and its safety even in infancy, graft patency, growth potential, graft longevity and clinical efficacy have been well documented. In this article the author reviews the development of pediatric coronary bypass as the main indication for the treatment of coronary lesions due to KD. I believe that coronary revascularization surgery in pediatric population utilizing uni- or bilateral ITAs is the current gold-standard as the most reliable treatment, although percutaneous coronary intervention with or without a stent has been tried with vague long-term results in children.

Paediatric coronary revascularization: a European multi-center study

Purpose: To evaluate the hospital and long term results of different surgical revascularization techniques in paediatric patients within the European Congenital Heart Surgeons Association (ECHSA). Methods: From 1969 to 2011, 80 patients from 13 ECHSA centers underwent 65 Paediatric Coronary Artery Bypass Grafting (PCABG) and 27 Other Coronary Artery Procedures (OCAP) (12 patients combined PCABG and OCAP). Excluded were patients with Kawasaki disease. Median age at the time of coronary procedure was 2.3 years (range 2 days–16.9 years); 33 patients (41.2%) were younger then 12 months. An emergency procedure was necessary in 34 patients (42.5%). Results: Twelve patients (15%) died in hospital; age at surgery (p=0.02) and the need for an emergent procedure (p=0.0004) were related to hospital mortality. Median follow-up time was 7.6 years (range 0.9–23 years). There were 3 late cardiac deaths, all after a median time of 4 years (range 9 months-8.8 years) from PCABG. Fourteen of 64 patients (21.8%) presented with symptoms, including congestive heart failure (n=10) and angina (n=5) that were related to a low ejection fraction (p<0.001) and the presence of moderate/severe mitral valve regurgitation (p=0.0003). Six patients underwent a re-intervention for impaired myocardial perfusion; all of them had a stenotic/atretic PCABG (p=0.001) and the majority were symptomatic (5/6 pts, 83.3%, p=0.001). Conclusions: PCABG and OCAP are suitable surgical options in paediatric patients with impaired myocardial perfusion which increases operative and mid-term survival.

Pediatric Coronary Artery Revascularization: A European Multicenter Study

We sought to evaluate the hospital and midterm results of different surgical revascularization techniques in pediatric patients within the European Congenital Heart Surgeons Association. From 1973 to 2011, 80 patients from 13 European Congenital Heart Surgeons Association centers underwent 65 pediatric coronary artery bypass grafting (PCABG) and 27 other coronary artery procedures (OCAP; 12 patients had combined PCABG and other coronary artery procedures). Excluded were patients with Kawasaki disease. Median age at the time of coronary procedure was 2.3 years (range, 2 days to 16.9 years); 33 patients (41.2%) were younger then 12 months. An emergency procedure was necessary in 34 patients (42.5%). Twelve patients (15%) died in the hospital; age at surgery (p=0.02) and the need for an emergent procedure (p=0.0004) were related to hospital mortality. Median follow-up time was 7.6 years (range, 0.9 to 23 years). There were 3 late cardiac deaths, all after a median time of 4 years (range, 9 months to 8.8 years) after PCABG. Fourteen patients (20.5%) presented with symptoms, including congestive heart failure (n=10) and angina (n=4), that were significantly associated with a low ejection fraction (p<0.001) and the presence of moderate or severe mitral valve regurgitation (p=0.0003). Six patients underwent a reintervention for impaired myocardial perfusion; all of them had a stenotic or atretic PCABG (p=0.001), and the majority were symptomatic (5 of 6 patients; 83.3%; p=0.001). Both PCABG and other coronary artery procedures are suitable surgical options in pediatric patients with impaired myocardial perfusion, which increases operative and midterm survival. Such population of patients needs to be followed for life to prevent and treat any possible cause of further myocardial ischemia.

Paediatric coronary artery bypass grafting for coronary hypoperfusion late after arterial switch operation

A case of left main coronary artery stenosis is presented in a boy late after an arterial switch operation, with significant ischaemia during exercise with good collateralisation through the right coronary artery. The problem was successfully managed with minimally invasive off-pump coronary artery bypass through median re-sternotomy.

Internal Mammary Artery Grafting for Coronary Hypoperfusion in Children

Pediatric coronary artery bypass is performed for ischemic complications of Kawasaki disease, congenital coronary anomalies, and iatrogenic pediatric coronary artery problems. We performed myocardial revascularization using the internal mammary artery in 6 children. A review of outcomes is presented here. Patient ages ranged from 7 days to 10 years. There was no operative mortality. All coronary bypass grafts were patent at 3 months to 3 years postoperatively. No patient had recurrent angina or showed signs of myocardial ischemia. Internal mammary artery bypass grafting can be successfully performed in infants and children with good results. Long-term patency and growth of the anastomosis of the distal vessel are not clear, but good clinical and angiographic results have been reported even after 25 years.

Midterm outcomes of myocardial revascularization in children

Pediatric coronary artery bypass grafting is uncommon. Small target vessels and appropriate conduit choice are the main technical challenges. Fourteen patients undergoing coronary artery bypass grafting from January 1986 to December 2008 were retrospectively reviewed. Median age was 10 years (range, 3-15 years); median weight was 36 kg (range, 12-71 kg). Indications included symptoms or evidence of inducible ischemia and angiographically documented coronary stenosis. Diagnoses included Kawasaki disease (5/14), anomalous left coronary artery originating from the pulmonary artery (2/14), previous stent implant (1/14), and metabolic disease (3/14). The remaining 3 patients had coronary stenosis after other cardiac operations. Preoperatively 5 patients (45%) had no symptoms and 9 (64%) had positive stress test. Single-vessel disease was demonstrated in 2 (14%), double-vessel disease in 7 (50%), triple-vessel disease in 1 (7%), and left main coronary artery involvement in 4 (29%). With standard cardiopulmonary bypass, 18 (81%) in situ internal thoracic arteries and 4 (19%) long saphenous veins were grafted. There was 1 early reoperation for graft failure. All patients survived to hospital discharge. Follow-up angiography was performed in 5 patients (36%; median, 2 years; range, 1 day-10 years), and 1 (7%) required late balloon dilatation. Median follow-up was 3.3 years (1 month-10 years), and 12 patients had no symptoms. There was 1 late death of noncardiac cause. Pediatric coronary artery bypass grafting can be performed for a wide range of indications. Midterm results are excellent. Preoperative stress testing can detect silent myocardial ischemia.

Long-term success of CABG in Kawasaki disease

Original article Kitamura, S. et al. Twenty-five-year outcome of pediatric coronary artery bypass surgery for Kawasaki disease. Circulation 120, 60–68 (2009). PubMed

Kawasaki Disease

Kawasaki disease (KD) is an acute systemic inflammatory illness that occurs predominately in children <5 years of age. The reported incidence varies widely depending on the ethnicity of the population and the method of case ascertainment. Recent reports would suggest the annual incidence is ≈20 to 25 per 100 000 children <5 years of age in North America, with the highest reported incidence of 188 being in Japan, where the disease was first described in 1967.1 The illness is self-limited and of unknown cause, but is complicated by a systemic vasculitis with a predilection for small- to medium-sized arteries, particularly the coronary arteries. The majority of patients will have either transient coronary artery dilation or no coronary artery luminal changes as noted on echocardiography. Long-term prognosis for these patients is considered to be excellent. Coronary artery aneurysms occur in 25% of patients, but the prevalence is reduced to ≈4% for patients treated with intravenous immunoglobulin infusion within 10 days of illness onset. Aneurysms are associated with an intense inflammatory cell infiltrate, destruction of the internal elastic lamina, and smooth muscle cell death. Coronary artery involvement is usually maximal within 6 to 8 weeks after the acute episode. Regression of aneurysms can occur primarily through myointimal proliferation, although the arterial structure and function remains abnormal,2 and there is an important ongoing risk of stenoses and occlusions.3 Long-term cardiology assessment and management is required, and some of these patients may require revascularization procedures or, rarely, cardiac transplantation. KD has become the most prevalent acquired cardiac disease in children in developed countries. Article see p 60 Although coronary artery complications are the predominant cause of morbidity and mortality, other cardiovascular abnormalities can occur. Valvulitis is a less prevalent complication, and there have been case reports of important long-term aortic and …

Twenty-Five-Year Outcome of Pediatric Coronary Artery Bypass Surgery for Kawasaki Disease

The long-term outcome of pediatric coronary artery bypass for patients with severe inflammatory coronary sequelae secondary to Kawasaki disease is unknown. One hundred fourteen children and adolescents ranging in age from 1 to 19 (median, 10) years at operation were followed up for as long as 25 years with a median of 19 years. The number of distal anastomoses was 1.7+/-0.8 per patient, and the internal thoracic artery was used in all but 3, most frequently for left anterior descending artery lesions. Saphenous vein grafts were used in 24 patients, mostly for non-left anterior descending artery lesions. Patients underwent multiple angiograms to evaluate their coronary and graft status. There was no operative or hospital mortality. Both 20- and 25-year survival rates were 95% (95% confidence interval [CI], 88 to 98). Five deaths occurred, all cardiac in origin. Cardiac event-free rates at 20 and 25 years were 67% and 60% (95% CI, 46 to 72), respectively. Percutaneous coronary intervention and reoperation were the most common events. Overall, the 20-year graft patency rate was 87% (95% CI, 78 to 93) for internal thoracic artery grafts (n=154) and 44% (95% CI, 26 to 61) for saphenous vein grafts (n=30) (P<0.001), and the rate for non-left anterior descending artery lesions was also significantly better for arterial grafts (87% [95% CI, 73 to 94]; n=59) than for saphenous vein grafts (42% [95% CI, 23 to 60]; n=27) (P=0.002). Eighty-eight patients (77%) remain on medications, but all 109 survivors are presently symptom free in their daily activities. Although the 25-year survival was excellent after pediatric coronary bypass for Kawasaki disease, the event-free rate declined progressively. This reality mandated continued follow-up. Reinterventions successfully managed most cardiac events. An internal thoracic artery graft was the most favorable for children.

Thermal coronary angiography in pediatric coronary artery bypass grafting

A 2-year-old boy was referred to our institution for treatment of coronary artery obstruction after an arterial switch operation (ASO). We performed a pediatric coronary artery bypass graft (CABG) with skeletonized left internal thoracic artery (LITA). The patient was 88 cm tall and weighed 11 kg. The left anterior descending (LAD) coronary artery was also identified about 1 mm in diameter. Anastomotic failure of imposed stricture was detected with an infrared camera (IRIS-V, VERITAS, Tokyo, Japan). In the situation of CABG, thermal coronary angiography (TCA) is very useful to reveal satisfactory blood flow into the left coronary system during this procedure.

Clinical pathways — a Middle–Eastern perspective

Clinical pathways were first developed at Sheikh Khalifa Medical Centre (SKMC), Abu Dhabi, in 2001 – one year after the facility first opened. Long lengths of stay and unjustified variances in clinical practice were the main reasons for the development. Laparoscopic cholcyctectomy was the first to be implemented six months after development began. Convincing the workgroup members to buy into clinical pathways was difficult in the initial stages of development, but after highlighting the benefits of clinical pathways, they became more receptive to change. Other problems that were faced during the development was the limited use of clinical pathways in the region, the rapidly changing workforce, the cultural/religious need of the patient and varied knowledge base among nursing staff. There were also many advantages to developing pathways in the Middle East; diverse workforce and an ever-changing work environment helped to make clinical pathways at SKMC effective in delivering high standards of care. There are currently nine clinical pathways: surgical, medical and paediatric, and two in development – paediatric acute gastroenteritis and coronary artery bypass grafting. Lengths of stay have been reduced since implementing clinical pathways, some more significant than others. In future months, clinical pathways will be in electronic format and will be known as power plans.

Pediatric coronary artery bypass for Kawasaki, congenital, post arterial switch, and iatrogenic lesions

Background. Pediatric coronary artery bypass (PCAB) has been recently employed for expanding indications to treat acquired, congenital, post arterial switch, and other iatrogenic pediatric coronary artery problems. Methods. Between 1987 and 1998, 3 infants and 13 children (n = 16, mean age 6.1 years, range 2 months–18 years) underwent one or more internal thoracic artery (ITA) to coronary artery (CA) bypass grafts for Kawasaki disease (n = 4), congenital lesions (n = 3), post arterial switch (n = 4), and other iatrogenic obstructions (n = 5). Proximal left main CA arterioplasty was performed concurrently with ITA-CA bypass in 4 patients. Results. Survival is 93.8%. All bypass grafts in surviving patients are patent 2 months–11 years postoperation. The 11 elective patients are well (NYHA I–II). The 5 emergent operations were performed in 2 infants and 3 adolescents who had poor ventricular function prior to ITA-CA bypass due to iatrogenic injuries in 3, congenital critical left main stenosis in 1, and intraoperative iatrogenic coronary injury in 1. The 3 adolescents fared worse, resulting in death in the first, cardiac transplantation in the second, and full recovery in the third. The 2 infants have steadily improving ventricular function. Conclusions. ITA-CA bypass can be successfully performed in infants and children for expanding elective and life-saving indications with excellent results. Poor preoperative ventricular function often persists, especially in those older children with iatrogenic injuries, and may result in death or cardiac transplantation.

Expanding indications for pediatric coronary artery bypass

Pediatric coronary artery bypass has been done mostly for ischemic complications of Kawasaki disease. We reviewed our clinical experience between 1987 and 1994 with internal thoracic artery–coronary artery bypass in one infant and five children for varying indications. Indications for coronary bypass included Kawasaki disease (2), congenital left main coronary ostial stenosis, iatrogenic coronary cameral fistula, anomalous origin of the left coronary artery from the pulmonary artery, and single coronary artery traversing between the great arteries in a patient after cardiac transplantation. An additional cohort of 34 control patients of various ages and weights (1 day to 16.1 years, 2.6 kg to 62 kg) had angiographic measurements of the right coronary, left coronary, and left internal thoracic arteries with respect to the feasibility of performing coronary artery bypass. All six patients survived internal thoracic artery–left anterior descending coronary artery bypass without evidence of perioperative myocardial infarction. Postoperative angiographic studies in five and color Doppler echocardiography in one showed graft patency. Retrospective angiographic measurements in the 34 control patients showed that internal thoracic and coronary arteries are proportionately quite large in neonates and infants compared with those in older children and adolescents. Internal thoracic artery–coronary artery bypass should be considered for the expanding indications presented herein and when emergency intraoperative life–threatening situations present themselves. Long–term patency and reoperation rates have yet to be determined. (J T HORAC C ARDIOVASC S URG 1996;111:181-9)