Surgery for coronary heart disease due to mucocutaneous lymph node syndrome (Kawasaki disease). Report of 6 patients.

Early and late surgical results in 6 patients with coronary heart disease secondary to mucocutaneous lymph node syndrome (MLNS) (Kawasaki disease) are presented. There were 5 male patients and 1 female patient, ranging in age from 2.5 to 26 years at the time of operation. They had severe coronary artery narrowings, obstructions, and aneurysms with or without mitral regurgitation. Previous myocardial infarction was documented in 5 patients. Aortocoronary bypass grafting utilizing the autologous saphenous vein was performed in 5 patients; in the remaining patient, mitral valve replacement was carried out. No operative or late deaths have been encountered. A long-term bypass graft patency was demonstrated in patients aged 26, 17, and 10 years with resulting clinical, angiographic, or scintigraphic improvements, or a combination of these. However, the graft that had been patent in a 4-year-old boy was found completely obstructed 3 years after surgery without any symptomatic changes. The formation of rich collateral channels was found. The risk of saphenous vein graft closure may be high in young growing children. In older children or adolescents, however, coronary vein bypass grafting for this specific inflammatory coronary artery lesion has been effective with long-term graft patency. Severe mitral regurgitation is also an indication for surgery, but poor left ventricular function associated with mitral regurgitation, probably secondary to myocarditis, persists after surgery and may give rise to future problems.

Severe mitral regurgitation due to coronary arteritis of mucocutaneous lymph node syndrome. A new surgical entity.

Case histories are reported of three patients, 1 to 4 years of age, with severe mitral regurgitation that occurred as a sequela of mucocutaneous lymph node syndrome (MCLS). These patients were found among 12 patients with coronary artery lesions such as aneurysms, narrowings, and obstructions. One of them with multiple coronary aneurysms and also severely impaired left ventricular function died of congestive heart failure in the 2 years and 7 months' follow-up period after the acute illness. The second patient, 1 year of age, had multiple coronary aneurysms and mitral regurgitation. Because of the difficulty in treating coronary artery lesions at this patient's age and also because of medically controllable mitral regurgitation at present, this patient is now under careful observation. The third patient, whose condition was complicated by inferior wall myocardial infarction due to occlusion of the right coronary artery, underwent mitral valve replacement for intractable heart failure and cardiac cachexia. This patient had slow but definite improvement postoperatively. Mitral regurgitation secondary to MCLS usually is complicated by the associated difficult coronary artery lesions and impaired left ventricular function. Although this fact causes an extra-difficult situation, mitral regurgitation consequent to MCLS is amenable to surgical treatment and this disease should now be considered as a new surgical entity.

Rubella epidemic in an institution: protective value of live rubella vaccine and serological behavior of vaccinated, revaccinated and naturally immune groups.

A rubella epidemic occurred in an institutional population composed of 189 susceptible, 37 naturally immune, 35 previously vaccinated and 38 serologically uncharacterized children and nursing staff. The epidemic lasted 3.5 months and showed more than 5 waves. Detailed clinical and serological examinations of these subjects were made. A rash appeared in 156 (52%) of 299 persons, including 145 (87%) of 166 unvaccinated and serologically uncharacterized subjects, but not in the 72 immune persons. In the middle of the 3rd wave urgent vaccination of 61 children aged 0 to 2 years of the susceptible group reduced the rate of appearance of a rash to 11 of the children (18%), as compared with 126 (98%) of 128 subjects in the unvaccinated non-immune group. The epidemic only reached a 4th wave in the vaccinated group, but it extended to a 5th wave or more in unvaccinated subjects. None of the 35 subjects in a previously vaccinated group developed rubella, although the rate of subclinical reinfection in this previously vaccinated group was higher (35%) than that in the naturally immune group (17%). Three cases of subclinical reinfection were detected even among 6 previously revaccinated subjects.

Long-term results in surgical treatment of children 4 years old or younger with coronary involvement due to Kawasaki disease.

Problems in myocardial revascularization for coronary impairment due to Kawasaki disease were assessed in five patients 1 to 4 years old. Each patient had significant stenosis or complete obstruction with aneurysm formation. There were no operative or late deaths in the follow-up period of 1 to 10 years after operation. The coronary arteries, including the first diagonal branch and obtuse marginal branch, were 1 to 1.5 mm in diameter. Eight saphenous vein grafts used were 2.5 to 3.5 mm in diameter and the internal mammary arteries used in two patients, ages 2 and 4 years, were 1 mm in diameter. All nine grafts examined in the early postoperative period were patent. However, only three of eight saphenous vein grafts were patent in the late postoperative studies. One saphenous vein graft to the right coronary artery was found patent 7 years after surgery in a patient who had been operated on at the age of 3 years. Internal mammary artery grafts used in the last two patients in the series were both patent throughout the late postoperative period. This experience suggests that myocardial revascularization is surgically feasible and beneficial even in young children and that further study is warranted.