Surgical myocardial revascularization outcomes in Kawasaki disease: systematic review and meta-analysis

Abstract

Background Kawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and early and long-term outcomes. Methods A systematic review using Medline, Cochrane, and Scopus databases was performed in February 2020, incorporating a network meta-analysis, performed by random-effect model within a Bayesian framework, and pooled prevalence of adverse outcomes. Hazard ratios (HR) and corresponding 95% credible intervals (CI) were calculated by Markov chain Monte Carlo methods. Results Among 581 published reports, 32 studies were selected, including 1,191 patients undergoing CABG for KD. Graft patency of internal thoracic arteries (ITAs), saphenous veins (SV), and other arteries (gastroepiploic artery and radial artery) was compared. ITAs demonstrated the best patency rates at long-term follow-up (HR 0.33, 95% CI: 0.17–0.66). Pooled prevalence of early mortality after CABG was 0.28% (95% CI: 0.00–0.73%, I 2 = 0%, tau2 = 0), with 63/1,108 and 56/1,108 patients, undergoing interventional procedures and surgical re-interventions during follow-up, respectively. Pooled prevalence was 3.97% (95% CI: 1.91–6.02%, I 2 = 60%, tau2 = 0.0008) for interventional procedures and 3.47% (95% CI: 2.26–4.68%, I 2 = 5%, tau2 <0.0001) for surgical re-interventions. Patients treated with arterial, venous, and mixed (arterial plus second venous graft) CABG were compared to assess long-term mortality. Mixed CABG (HR 0.03, 95% CI: 0.00–0.30) and arterial CABG (HR 0.13, 95% CI: 0.00–1.78) showed reduced long-term mortality compared with venous CABG. Conclusions CABG in KD is a safe procedure. The use of arterial conduits provides better patency rates and lower mortality at long-term follow-up.

Coronary Revascularization in Patients With Cardiac Sequelae of Kawasaki Disease at a Single Center

“…Only one patient presented deterioration of ventricular function (the patient who from weaning cardiopulmonary bypass required ventricular support for 7 h) without modifying the overall result of the cohort. There was no operative or follow-up mortality, coinciding with previous reports where early mortality is low (0.28%), 14 and in the follow-up at 20 and 25 years, it reached 5%. 13…”

“…Only one patient presented deterioration of ventricular function (the patient who from weaning cardiopulmonary bypass required ventricular support for 7 h) without modifying the overall result of the cohort. There was no operative or follow-up mortality, coinciding with previous reports where early mortality is low (0.28%), 14 and in the follow-up at 20 and 25 years, it reached 5%. 13 It is important to mention that in our institution, there have been no cardiac events (acute myocardial infarction, angina pectoris, syncope, or ventricular tachyarrhythmias) or indications for percutaneous coronary intervention or surgical reintervention, which according to Salsano et al 14 can reach up to 3.9% and 3.4%, respectively.…”

“…It is important to mention that in our institution, there have been no cardiac events (acute myocardial infarction, angina pectoris , syncope, or ventricular tachyarrhythmias) or indications for percutaneous coronary intervention or surgical reintervention, which according to Salsano et al 14 can reach up to 3.9% and 3.4%, respectively.…”

“…CABG for patients with KD and cardiac sequelae has proven to be an adequate treatment option to improve myocardial ischemia. Since it was performed for the first time in 1975, 11 called Kitamura operation, 3,11,12 the surgical methodology has evolved from the use of venous grafts to the current use of arterial grafts, mainly the internal thoracic arteries, 3,7,[13][14][15] based on the long-term patency of the graft. Studies have shown that isolated autologous saphenous vein graft was inferior with relation to arterial grafts (internal thoracic arteries, radial arteries, and gastroepiploic artery), 3,13,16 supported by the observation that these grafts develop according to the age and growth of the pediatric patient.…”

Surgical treatment of coronary artery lesions in children with Kawasaki disease

“…The available graft materials mainly include the autologous internal thoracic artery, large saphenous vein, radial artery, and right gastric omental artery. Overall, the long‐term patency rate of arterial bridge vessels (internal thoracic artery, gastroepiploic artery, radial artery, and subabdominal wall artery) was higher than that of venous bridge vessels (large saphenous vein) 4 . Yoshikawa et al reported long‐term patency rates of 1%, 5%, 82%, 94%, and 78% for arterial bridges and 1%, 5%, 10%, 82%, 63%, and 36% for large saphenous vein bridges.…”