本帖最後由 lsc0019 於 2009-7-21 23:40 編輯
作者：Laurie Barclay, MD
出處：WebMD醫學新聞
July 7, 2009 — 根據一項於6月22日線上發表於循環期刊的研究結果，冠狀動脈繞道手術（CABG）提供罹患川崎氏症（KD）兒童的心臟併發症有長期助益。
來自日本大阪國家心臟中心的Soichiro Kitamura醫師寫到，因罹患川崎氏症造成嚴重發炎冠狀疾病的兒童病患，接受冠狀動脈繞道手術的長期預後是未知的；我們描述114位因為KD併發症而接受手術之病患的長期預後，這樣的併發症是兒童冠狀動脈疾病最常見的原因。
這群病例包括114位接受CABG時介於1至19歲的兒童與青少年（平均年齡為10歲），平均後續追蹤時間為19年（最長達25年），每位病患的遠端血管縫合數目為1.7±0.8。所有病患都使用胸內動脈，除了3位病患之外，最常因為左前降支狹窄接受手術，有24位病患接受隱靜脈移植，主要是因為影響到其他的動脈，冠狀與移植血管狀況以多重血管攝影評估。
試驗中沒有與手術相關或住院死亡事件。5個死亡事件都是發生在後續追蹤期間，且都與心臟有關。在20年與25年時的存活率是95%（95%信賴區間[CI]為88%-98%），未發生心臟事件的存活率，在20年時為67%，在25年時為60%（95% CI為46%-72%）。最常發生的事件為經皮冠狀動脈介入與再度手術。雖然有88位病患（77%）繼續接受藥物治療，但所有109位存活者，目前在日常活動時並沒有症狀。
在20年時，整體移植血管暢通率，在內胸動脈為87%（95% CI為78%-93%）、隱靜脈移植為44%（95% CI為26%-61%）（共30位；P<0.001）。相較於隱靜脈移植血管（42%；95% CI為23%-60%；共27位；P=0.002），對非左前降支病灶，暢通率顯著較高（87%；95% CI為73%-94%；共59位）。
研究作者們寫到，雖然兒童川崎氏症接受冠狀動脈繞道的25年存活率是很好的，未發生事件的機率逐漸下降。這個事實告訴我們需要持續後續追蹤。再次介入成功地處理大部分心臟事件。
這項研究的限制包括觀察性設計與可能的選擇性誤差。
研究作者們的結論是，內胸動脈（ITA）血管移植是兒童最偏好的。使用ITA進行兒童冠狀動脈手術應該作為因為KD嚴重冠狀動脈疾病的治療。
在隨後的主編評論中，來自加拿大安大略多倫多兒童醫院的Brian W. McCrindle醫師表示，大部分罹患KD病患將會被期待存活至成人。
McCrindle醫師寫到，成功地轉換到成人照護將是個重要的議題。如果有關於預後的擔憂仍需要解決，就一定要追蹤到成人。同時，所有病患都應該謹慎且被建議健康生活型態，以及接受心血管疾病因子篩檢與治療。
研究作者們與McCrindle表示沒有相關資金上的往來。
Coronary Artery Bypass Surgery Helpful During Long-Term for Children With Kawasaki Disease
By Laurie Barclay, MD
Medscape Medical News
July 7, 2009 — Coronary artery bypass graft (CABG) surgery offers long-term benefits for children with cardiovascular complications of Kawasaki disease (KD), according to the results of a study reported in the June 22 Online First issue of Circulation.
"The long-term outcome of pediatric coronary artery bypass for patients with severe inflammatory coronary sequelae secondary to Kawasaki disease is unknown," write Soichiro Kitamura, MD, from the National Cardiovascular Center in Osaka, Japan, and colleagues. "We describe the long-term outcome of...114 patients after their surgery for KD coronary complications, presently the world's most common cause of pediatric coronary artery disease."
This case series consisted of 114 children and adolescents aged 1 to 19 years (median age, 10 years) when undergoing CABG. Median follow-up was 19 years (maximum, 25 years). The mean number of distal anastomoses per patient was 1.7 ± 0.8. The internal thoracic artery was used in all but 3 patients, most frequently for left anterior descending artery stenosis, whereas 24 patients had saphenous vein grafting, primarily for lesions affecting other arteries. Coronary and graft statuses were evaluated with multiple angiograms.
There were no operative or in-hospital deaths. All 5 deaths occurring during follow-up were cardiac in origin. Survival rates at 20 and 25 years were 95% (95% confidence interval [CI], 88% - 98%). Cardiac event–free rates were 67% at 20 years and 60% at 25 years (95% CI, 46% - 72%). The most prevalent events were percutaneous coronary intervention and reoperation. Although 88 patients (77%) continued to receive medications, all 109 survivors are currently asymptomatic when performing their daily activities.
At 20 years, the overall graft patency rate was 87% (95% CI, 78% - 93%) for internal thoracic artery grafts (n = 154) and 44% (95% CI, 26% - 61%) for saphenous vein grafts (n = 30; P < .001). For non–left anterior descending artery lesions, patency was also significantly better for arterial grafts (87%; 95% CI, 73% - 94%; n = 59) vs saphenous vein grafts (42%; 95% CI, 23% - 60%; n = 27; P = .002).
"Although the 25-year survival was excellent after pediatric coronary bypass for Kawasaki disease, the event-free rate declined progressively," the study authors write. "This reality mandated continued follow-up. Reinterventions successfully managed most cardiac events."
Limitations of this study include observational design and possible selection bias.
"An internal thoracic artery [ITA] graft was the most favorable for children," the study authors conclude. "Pediatric coronary bypass surgery with the use of the ITA should be an established treatment for severe coronary disease due to KD."
In an accompanying editorial, Brian W. McCrindle, MD, MPH, from The Hospital for Sick Children, Toronto, Ontario, Canada, notes that most patients with KD will be expected to survive into adulthood.
"Successful transition to adult care is an important issue," Dr. McCrindle writes. "Outcomes must be tracked seamlessly into adulthood if ongoing concerns about prognosis are to be resolved. In the meantime, advocacy for healthy lifestyle and screening and management of cardiovascular risk factors for all patients is prudent and recommended."
The study authors and Dr. McCrindle have disclosed no relevant financial relationships.
Circulation. Published online June 22, 2009. |
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