川崎病患儿冠状动脉血流储备测定与影像形态学诊断的对照研究

Coronary flow reserve measurement and coronary anatomic imaging in children with Kawasaki disease

目的评价持续冠状动脉病变对川崎病（KD）患儿冠状动脉血液动力学的影响,探讨冠状动脉血流储备（CFR）检测在KD患儿冠状动脉病变远期随访中的应用价值。方法选择因胸痛、心悸以及各类偶发早搏的患儿为对照组,KD并发持续左冠状动脉病变患儿为KD组,均予以ATP160μg·kg^-1·min^-1持续静脉注射,共6min。运用经胸多普勒超声心动图（TTDE）检测冠状动脉左前降支（LAD）在ATP注射前后的舒张期峰值流速（PDV）及平均流速（MDV）,并通过计算比值得出相应CFR（PDV）和CFR（MDV）值。结果对照组纳入25例,CFR（PDV）和CFR（MDV）值均与年龄呈显著正相关（r=0.596,0.591,P=0.002,0.002）;〈2岁、-8岁和〉8岁组的CFR（PDV）95%参考值范围分别为≥1.22、≥1.94和≥2.22。KD组纳入8例,静息状态下PDV和MDV值分别为（50.0±15.07）cm.s^-1和（35.16±11.52）cm.s^-1,显著高于对照组（P=0.004,0.015）;而CFR（PDV）和CFR（MDV）值明显降低,分别为（1.67±0.38）cm.s^-1和（1.69±0.47）cm.s^-1（P=0.002,0.018）。与对照组比较,KD组7/8例（87.5%）患儿CFR（PDV）值显著降低。结论持续冠状动脉病变可导致KD患儿CFR值显著降低,TTDE检测患儿CFR具无创、安全和便捷的优点,对于KD冠状动脉病变的长期随访与临床诊断治疗策略的选择具有指导意义。

Objective To evaluate the physiologic effects of the persistent coronary sequelae of Kawasaki disease（KD） on coronary hemodynamics and to investigate the clinical value of coronary flow reserve（CFR） measurement by transthoracic Doppler echocardiography（TTDE） in long term follow-up of coronary lesion in children with KD.Methods The control group consisted of 25 control subjects[aged 7 months to 11.5 years,mean（5.4±3.5） years] and KD group consisted of 8 KD patients[aged 1.9-14.4 years,mean（7.1±4.5） years;5 months to 9.7 years after the onset of KD,mean（2.8±3.2） years]with persistent coronary sequelae in the left coronary artery.The peak diastolic velocity（PDV） and mean diastolic velocity（MDV） in distal left anterior descending coronary artery（LAD） were measured at rest by TTDE in all children.After stable baseline signals were obtained,adenosine triphosphate（ATP） was administered intravenously at a dose of 160μg·kg-1·min-1 sustained for six minutes.Data were recorded at rest and during the last minute of ATP infusion.The ratio of the hyperemic PDV or MDV to baseline was calculated as an index of CFR（PDV） or CFR（MDV）.The three main branches of coronary arteries in all KD patients were evaluated carefully by TTDE for the presence of coronary lesions,including ectasia,aneurysm,stenosis and thombi.And 5 of 8 patients underwent computerized tomography arteriography or coronary angiography for further investigation.Results Among the 25 control subjects,CFR values calculated from PDV and MDV both indicated significantly positive correlation with age（r=0.596,0.591,P=0.002,0.002）.The 95% confidence interval of normal CFR（PDV） data were categorized by age as follows： ≥1.22（〈2 years）,≥1.94（-8 years） and ≥2.22（〉8 years）.The baseline PDV and MDV were（50.0±15.07） cm·s^-1 and（35.16±11.52） cm·s-^1 in KD patients,respectively,much higher than those of control group（P=0.004 and 0.015）,while CFR values were much lower [1.67±0.38 and 1.69±0.47（P=0.002 and P=0.018）].A significant reduction in CFR was noted in 7 of 8 patients（87.5%） as compared with control subjects.The coronary morphology investigation confirmed aneurysm in left main coronary artery（LM） in one child,coronary aneurysms in LAD in five,aneurysm combined with multiple severe stenosis of LAD in one and aneurysm in LM with complete occlusion of left circumflex coronary artery（LCx） in one.Conclusions The present study indicated that coronary flow reserve was reduced in KD patients due to persistent epicardial coronary lesions.CFR measurement by TTDE was non-invasive,technically easy and safe,with great value for long term follow-up and management of patients with persistent coronary abnormalities of KD.