川崎病并冠状动脉血栓35例超声心动图随访及临床回顾分析

Echocardiographic and clinical retrospective study of 35 patients with Kawasaki disease combined with coro- nary artery thrombosis

目的总结儿童川崎病（KD）并冠状动脉血栓（CAT）的超声心动图随访结果及临床特征。方法收集2005年7月至2016年8月首都医科大学附属北京儿童医院确诊的35例KD并CAT患儿的临床资料，回顾性分析其超声心动图随访结果及急性期、恢复期临床特点。根据患儿病程中是否出现心肌缺血，将其分为心肌缺血组和非心肌缺血组，对2组患儿急性期发热持续时间，首次静脉注射免疫球蛋白（IVIG）时间，冠状动脉瘤（CAA）形成时间、CAA最大内径峰值及急性期炎症指标等进行比较，分析可能导致心肌缺血的危险因素。结果35例KD并CAT患儿均存在冠状动脉瘤样扩张，血栓均于CAA内检出。共检出99支冠状动脉存在瘤样扩张，CAA内径峰值为（9．6±3．1）mm（4．0—19．0mm）。于CAA内共发现CAT54处。血栓形成的CAA内径大于无血栓形成者[（10．9±2．8）mm比（7．9±2．6）mm]，差异有统计学意义（P〈0．01）。随访4个月～10年8个月[（39．2±29．5）个月]，32支[32．3％（32／99支）]冠状动脉的CAA消退，其中4支[4．0％（4／99支）]冠状动脉内径完全恢复正常。CAA消退者冠状动脉内径峰值小于CAA未消退者[（7．3±1．9）mm比（10．6±3．0）mm]，差异有统计学意义（P〈0．001）。KD并CAT患儿中，15例[42．9％（15／35例）]出现心肌缺血，20例[57．2％（20／35例）]无心肌缺血表现。15例心肌缺血患儿中6例[17．1％（6／35例）]发生心肌梗死，4例[11．4％（4／35例）]出现心肌梗死后心力衰竭，1例[2．9％（1／35例）]患儿因心力衰竭并恶性心律失常死亡。与非心肌缺血组相比，心肌缺血组患儿急性期发热时间较长[（19．1±7．8）d比（12．1±3．3）d]、白细胞总数较高[（24．8±13．5）×10^12／L比（19．7±4．0）×10^12／L]、首次IVIG使用时间距发病较晚[（13．9±5．5）d比（9．8±3．8）d]、CAA形成时间较早[（16．0±4．9）d比（20．9±14．5）d]，2组比较差异均有统计学意义（均P〈0．05）。结论KD并CAT多发生于冠状动脉瘤样扩张基础上。其急性期炎症反应重，CAA形成早、程度重、消退缓慢者更易因CAT形成导致心肌缺血。超声心动图可动态监测CAA，及时检出血栓，早期发现左心室收缩功能受损，具有重要的临床应用价值。

Objective To summarize the echocardiographic findings and clinical characteristics of Kawasaki disease（KD） complicated with coronary artery thrombosis（CAT）. Methods Thirty - five patients with KD combined with CAT were enrolled, who were admitted to Beijing Children＇s Hospital, Capital Medical University between July 2005 and August 2016. The clinical characteristics and echocardiographic findings during follow - ups were retrospec- tively studied. According to whether the childrenhad been complicated with myocardial isehemia, the patients were di- vided into 2 groups ： ischemic group and non - ischemic group. The duration of fever, the time when the intravenous immunoglobulin（IVIG） was first injected, the time when coronary artery aneurysms（CAA） was formed, the maximum diameter of CAA and inflammatory index inthe acute phase were compared between 2 groups. Results All of the 35 children diagnosed as KD combined with CAT suffered from CAA, and the coronary thrombosis was detected in all the cases with aneurysms. Thirty - five patients had 99 branches of CAA, of which the maximum diameter of CAA was （9.6 ± 3.1 ） ram（4.0 - 19.0 ram）. Fifty - four plots of CAT were detected in the aneurysms. The diameter of CAA that thrombosis located was larger than that of which the thrombosis was not located [ （ 10.9 ± 2.8 ）mm vs. （ 7.9 ± 2.6 ） mm] , and the difference was significant （P 〈 0.01 ）. During 4 months to 10 years and 8 months [ （39.2 ± 29.5） months ] follow - ups, CAA regressed in 32 branches [ 32.3 % （ 32/99 branches ） ], of which 4 branches [ 4.0% （ 4/99 branches） ] completely regressed to the normal diameter. The maximum diameter of CAA regressed was smaller than the maximum diameter of CAA consistence [ （7.3 ± 1.9） mm vs. （ 10.6 ±3.0） mm ] , and the difference was signifi-cant（P 〈 0.01 ）. Out of 35 patients, 15 cases [ 42.9% （ 15/35 cases） had myocardial ischemia , while the other 20 cases[57.2% （20/35 cases） ] didnt have. Among 15 cases with myocardial ischemia, 6 cases[ 17.1% （6/35 cases） ] had myocardial infarction, 4 cases [ 11.4% （4/35 cases） ] had heart failure, and 1 case [ 2.9% （ 1/35 cases） ] died of acute heart failure complicated with severe ventricular arrhythmia. Compared with non - ischemic group, the children in the ischemic group had longer duration of fever[ （ 19.1 ±7.8） d vs. （ 12.1 ± 3.3） d] , higher white blood cell account in the acute phase [ （24.8 ± 13.5 ） × 10^12/L vs. （ 19.7 ± 4.0） x 1012/L ], later treatment of IVIG [ （ 13.9 ± 5.5 ） d vs. （9.8 ± 3.8） d ], and earlier CAA formation [ （ 16.0 ± 4.9） d vs. （20.9 ± 14.5 ） d ], and the differences were statistically significant （ all P 〈 0.05）. Conclusions CAT of children with KD commonly originates from CAA. Patients who have more serious inflammatory reaction in the acute phase, earlier formation, heavy severity and longer consistence of CAA are prone to have myocardial ischemia. Echocardiographic study plays an important role in monito- ring CAA, detecting the CAT and finding the early left ventricle dysfunction, which is of clinical significance.