Long-Term Outcomes of Pediatric Coronary Artery Bypass Grafting and Down-Sizing Operation for Giant Coronary Aneurysms

Abstract

There are several concerns regarding surgical revascularization for Kawasaki coronary disease, including the choice of conduit, optimal timing, and indications for coronary artery bypass grafting (CABG). The internal thoracic artery is the best conduit for pediatric CABG because of its favorable growth potential and long-term patency. Use of a saphenous vein graft should be avoided unless the internal thoracic artery is unavailable. Indications for CABG for Kawasaki coronary disease have not yet been established. In principle, coronary aneurysms should be observed continuously for 1–2 years under restrictive anticoagulation therapy, because coronary aneurysms regress in 50 % of patients within 1–2 years. Presence of severe ischemia with giant coronary aneurysms involving obstructive lesions of the left main trunk or left anterior descending artery (LAD) is an unequivocal indication for CABG. In addition, a giant aneurysm with recurrent thrombosis under restrictive anticoagulation therapy or with severely delayed flow without significant localized stenosis may be an indication for CABG. However, determining surgical indications is difficult, especially for younger children, because of technical challenges. To prevent fatal complications, CABG might be indicated at a young age for patients with severe ischemia, because a history of myocardial infarction and impaired cardiac function affect prognosis. Down-sizing operation for giant aneurysms of non-LAD lesions without significant stenosis and severe calcification may be a good choice to improve coronary circulation and allow discontinuation of warfarin, if indications for this procedure can be established.