川崎病巨大冠状动脉瘤的外科治疗(附5例报告)

Comprehensive surgical management of giant coronary artery aneurysm secondary to Kawasaki disease:5 cases report

目的探讨终末期川崎病(黏膜皮肤淋巴结综合征)合并冠状动脉瘤的临床特点、外科干预指征及手术方法。方法回顾性分析2006年5月-2007年10月经手术治疗的5例川崎病合并冠状动脉瘤患者的临床资料。患者年龄2～57岁,冠状动脉瘤体直径1·5～2·5cm,其中右冠状动脉多发冠状动脉瘤1例,左冠状动脉主干及前降支冠状动脉瘤2例,左、右冠状动脉瘤2例。术前心电图显示ST改变5例。心脏超声EF值明显减低4例,心衰急诊入院1例。冠状动脉造影右冠状动脉完全闭塞、心室壁运动幅度减低1例。手术方法包括体外循环直视下冠状动脉内膜剥脱、血栓清除、瘤体成形4例,其中1例同期行冠状动脉切口远端支架置入。另1例直接行冠状动脉搭桥术。结果无手术死亡,心脏全部自动复跳。术后ICU病程平稳,4例心电图ST段缺血改善、心脏超声EF值明显提高,1例ST段及EF值改善不显著。结论临床Ⅲ期以上川崎病合并冠状动脉瘤有明显临床症状者应外科干预,采用内膜剥脱、血栓清除、瘤体成形及冠脉搭桥等综合方法,结合术后抗凝及免疫治疗,可有效改善心肌缺血及心脏功能。

Objective To investigate the clinical features and surgical management of giant coronary artery aneurysm due to mucocutaneous lymph node syndrome（Kawasaki disease）.Methods From May 2006 to Oct.2007,5 patients with giant coronary artery aneurysm were undergone surgical correction.The aneurysm mainly appeared in the left bole of coronary artery and the right coronary artery.The ST segment of electrocardiogram changed in 5 cases,cardiac ejection fraction reduced observably in 4 cases,and 1 case suffered from cardiac dysfunction.Coronary angiography showed that the right coronary artery was entirely occluded and ventricular wall motion was depressed in one case.During operation,4 cases were undergone thrombus clearing,endoarterectomy and replasty of coronary artery（with additional procedure of stent placement in one case）,one case was undergone coronary artery bypass grafting（CABG） with the aneurysm sequestration.Results The surgical results were satisfactory.No operative death occurred,and all the patients recovered uneventfully and were free of symptoms.In 4 cases,the ST segment of electrocardiogram showed that the blood supply of ischemic myocardium was improved,and the cardiac ejection fraction increased obviously.With 2 to 18 months following-up,all patients were free of symptoms with no death or coronary artery aneurysm recurrence.Conclusions For stage 3 Kawasaki disease complicated with giant coronary artery aneurysm,surgical procedure is necessary.The cardiac function can be improved greatly after comprehensive treatment of thrombus clearing,endoarterectomy,replasty of coronary artery and CABG.