川崎病冠状动脉病变远期随访评估:二维超声与冠状动脉造影对照观察

Long-term follow-up assessment of coronary artery complications in children with Kawasaki disease:A comparision between echocardiography and coronary angiography

目的探讨体表十二导联心电图(ECG)、二维经胸超声心动图(2DE)、64排螺旋CT冠脉成像技术(MDCT)和选择性冠状动脉造影(CAG)在川崎病(KD)严重冠状动脉病变远期随访中的应用价值。方法回顾性分析2006年7月至2010年9月于复旦大学附属儿科医院随访的15例KD并发严重冠状动脉病变(美国冠状动脉分级Ⅲ～Ⅴ级)患儿的临床特征、治疗方案以及ECG、2DE、MDCT和CAG检查结果。结果 15例KD患儿进入分析,KD发病年龄为5个月至13.5岁,平均(4.8±1.1)岁;病程3～64个月,平均(17.4±13.0)个月。2例主诉反复心绞痛发作,2例表现为充血性心力衰竭,其余患儿无明显临床症状。ECG检查发现异常Q波及ST-T波改变3例;MDCT与CAG检查结果显示,在单支、两支和三支冠状动脉中发生巨大瘤样病变的患儿分别为5例、5例和3例;6例合并远端冠状动脉瘤;2例可见冠状动脉瘤内血栓形成,但未形成狭窄;4例存在冠状动脉严重梗阻性病变,其中右冠状动脉合并左回旋支完全闭塞1例,右冠状动脉合并左前降支严重狭窄2例,右回旋支完全闭塞1例。冠状动脉病变Ⅲ级1例,Ⅳ级10例,Ⅴ级4例。与MDCT、CAG结果对照,2DE诊断完全符合率为46.7%(7/15例),其中遗漏诊断远端冠状动脉瘤6例,冠状动脉严重狭窄和(或)闭塞4例,冠状动脉内附壁血栓1例。结论对于2DE诊断为严重冠状动脉病变的KD患儿,应予以进一步MDCT或CAG检查以了解冠状动脉病变全貌,为治疗策略的制定提供更多信息。

Objective To evaluate the diagnostic value of electrocardiography（ECG）,echocardiography（2DE）,muting-row detector computed tomography（MDCT）and selective coronary angiography（CAG）in the long-term management of Kawasaki patients with coronary artery complications.Methods The clinical data,therapeutic schedule and follow-up assessments of coronary lesions by using ECG,2DE,MDCT and CAG in the total of 15 Kawasaki patients with severe coronary involvement from Children＇s Hospital of Fudan University from July 2006 to September 2009 were retrospectively collected.Results The total of 15 patients,diagnosed as Kawasaki disease at mean age of 4 years and 9 months ±1 year and 1 month（range 5 months to 13 years and 6 months）,were followed up at a mean period of（17.4±13.0）months（range 3 to 64 months）after onset of the disease.During the convalescence phase,2 patients complained of recurrent angina pectoris,other 2 patients presented with the symptoms of congestive heart failure,and the remaining 11 patients were asymptomatic.The abnormal deep Q wave with ST-T change was revealed by electrocardiography in 3 patients.With the further investigation by using the computed tomography and coronary angiography,the giant aneurysms in 1,2 and 3 coronary vessels were identified in 5,5 and 3 patients,respectively.Additional distal aneurysm was found in 6 patients,and the intraluminal thrombi without causing stenosis were found in 2 patients.The severe occlusive lesions were confirmed in 4 patients,including complete occlusion of RCA and LCX in one patient,severe stenosis of LAD and RCA in two and left circumflex obliteration in one.According to the risk-level categories of coronary lesions,there were 1,10 and 4 patients in level Ⅲ,Ⅳ and Ⅴ,respectively.Compared with MDCT and CAG,the accuracy rate of 2DE was 46.7%（7/15）in this group.The distal aneurysms,severe occlusive lesions and intraluminal thrombus were not able to be visualized by 2DE in 6,4 and 1 patients,respectively.Conclusions The computed tomography or invasive coronary angiography can provide more information about coronary anatomy for long-term follow-up and management while the significant coronary complications are detected by two dimensional echocardiography.