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Midterm Outcomes of Myocardial Revascularization in Children
Nicola Viola, Abdullah A Alghamdi, Osman O Al-Radi, William G Williams, John G Coles, Glen S Van Arsdell, Christopher A Caldarone
Hospital for Sick Children, Toronto, ON, Canada
Background - Coronary artery bypass is an uncommon operation in the pediatric population. Clinical symptoms can underestimate the severity of the coronary disease and therefore thorough work-up is required. Small coronary artery diameter and the need for conduits suitable for long term growth represent the main technical challenges. This report examines the immediate and mid-term outcomes of children who underwent coronary artery bypass surgery at our institution.
Methods - Between 1980 and 2008, fourteen patients underwent coronary artery bypass grafting (CABG). The median age was 10 years (range 3-15 years) and the median weight 36 Kg (range 12 to 71 kg). Diagnoses were Kawasaki disease (n=5), ALCAPA (n=2), postsurgical (n=3), previous percutaneous coronary procedure (n=1) and other (n=3). All of the children had angiographically proven coronary stenosis: single vessel disease in 2 (14%), double vessel disease in seven (50%), triple vessels disease in 1 (7%), and left main coronary artery involvement in 4 (29%). 9 patients (64%) also had a positive stress test. Half of the patients with positive stress test and positive angiography had no angina or angina-like symptoms. All patients received one or two pedicled mammary artery grafts. Additional saphenous vein grafts (SVG) were used in four. In total, 22 grafts were used. Five patients had associated procedures, three of which involved the coronaries (Table I).
Basic descriptive analyses were performed including median, means and standard deviations for continuous variables and proportions for categorical variables. Individual patients’ data were tabulated where appropriate.
Results - There were no perioperative deaths. One patient who underwent proximal coronary arterioplasty required emergency CABG on post operative day 1 for early restenosis. Two patients had significant arrhythmias. The median length of hospital stay was eight days (range 3 to 24 days).
Postoperative angiography was performed in five patients (median interval to angiography 2 years - range 1 day to 10 years) based on clinical indications. One patient complaining of severe recurrent angina 12 months after surgery required balloon arterioplasty (PTCA) to a stenosed saphenous vein graft. The remaining four patients presented non-specific changes on routine follow-up stress tests and the subsequent angiograms were negative. Follow up time ranged from 0 to 10 years (median 3.3 years). At most recent follow up, 13 patients were asymptomatic and one was in severe cardiac failure. Mean left ventricular ejection fraction was 64% (range 58-72%). There was one late death due to a non-cardiac event (Table I).
Conclusion - Coronary artery bypass grafting can be performed in the pediatric population with excellent mid term results. Preoperative stress test can detect silent myocardial ischemia and absence of symptoms does not rule out significant coronary disease. | | | | | | | | | | | Case | Age (yr) | Weight (Kg) | Symptoms | Stress Test/Myoscan | Angiography | Procedure | Postoperative Angiography | Follow up (yrs) | Outcomes | | 1 | 10 | 14 | + | + | DVD | CABG X 2 | PTCA to SVG | 12 | Death | | 2 | 8 | 38 | _ | + | TVD | CABG X 3 + RCA Plasty | Patent Grafts, Patent RCA | 10 | Asymptomatic | | 3 | 9 | 20.5 | n/a | n/a | LMCA | CABG X 1 | | 10 | Asymptomatic | | 4 | 12.7 | 38.8 | + | + | LMCA | CABG X 2 + RCA Plasty | | 4 | Asymptomatic | | 5 | 13.6 | 41.5 | n/a | n/a | SDV | CABG X 1 | | 6 | Asymptomatic | | 6 | 12.7 | 37 | + | + | LMCA | CABG X 2 | | 3.3 | Asymptomatic | | 7 | 13 | 43.8 | + | _ | SDV | CABG X 1 | | 4.4 | Asymptomatic | | 8 | 13.8 | 71 | _ | + | DVD | CABG X 1 + LAD Unroofing | | 3.3 | Asymptomatic | | 9 | 9.4 | 65 | _ | _ | DVD | CABG X 2 | Patent Grafts | 3.4 | Asymptomatic | | 10 | 9.4 | 22.4 | + | + | SDV | CABG X 1 + MV Repair, ARR | Patent Grafts | 3.2 | NYHA FC III | | 11 | 2.6 | 12.2 | _ | + | DVD | CABG X 2 | Patent Grafts | 1.4 | Asymptomatic | | 12 | 10 | 38 | + | + | DVD | CABG X 4 | | 0.1 | Asymptomatic | | 13 | 11.6 | 41 | + | n/a | LMCA | CABG X 1 + Sub Aortic Memb Resection | | 0.1 | Asymptomatic | | 14 | 8.9 | 25.9 | _ | + | DVD | CABG X 2 | | 0.1 | Asymptomatic |
Table I.
SVD, Single Vessel Disease; DVD, Double Vessel Disease; TVD, Triple Vessel Disease. LMCA, Left Main Coronary Artery; MV, Mitral Valve; ARR, Aortic Root Replacement.
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