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The likelihood of regression is inversely proportional to the diameter of the aneurysm&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> CAAs in patients with onset in infancy&#44; proximal location&#44; or saccular form&#44; are also less likely to regress&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;6&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Persistent CAAs are prone to the development of stenosis&#44; tortuosity&#44; calcification and thrombosis&#59; they can be responsible for myocardial infarction &#40;&#60;5&#37;&#41; and death &#40;1-5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;7&#8211;9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 23-month-old male presented at his local hospital with desquamation of the extremities&#44; 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weighing 23&#46;1 kg and measuring 116 cm&#44; the patient was re-catheterized and progression of the previously documented lesions was noted&#46; He was asymptomatic&#46; Physical examination was unremarkable&#46; Coronary angiography showed a CAA of the LAD measuring 17 mm&#215;7 mm involving the first diagonal branch associated with a 90&#37; post-aneurysmal stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; and a CAA of the RCA measuring 32 mm&#215;6 mm&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was admitted and myocardial revascularization was proposed&#46; As ostial and long-segment lesions of important coronary arteries had been documented&#44; coronary artery bypass grafting &#40;CABG&#41; was the procedure of choice&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgery was performed under general anesthesia&#46; A standard median sternotomy was performed and the left internal mammary artery &#40;LIMA&#41; was harvested&#46; After administration of full-dose heparin&#44; cardiac bypass was established by cannulation of the ascending aorta &#40;16 Fr Medtronic DLP cannula&#41; and the right atrial appendage &#40;28 Fr Medtronic DLP&#41;&#46; Anastomosis of the pediculated&#44; non-skeletonized LIMA to the proximal LAD was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41; in the usual manner with an 8-0 polypropylene suture&#44; after ascending aortic clamping and anterograde administration of cold cardioplegic solution&#46; Intraoperative findings consisted of a LIMA with a diameter of 1&#46;5 mm and very good pulsatile flow and a LAD without signs of degeneration&#44; inflammation or calcification&#44; and a diameter of approximately 1 mm distal to the aneurysm&#46; Total bypass time was 28 minutes and total ischemic time was 14 minutes&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The postoperative period was uneventful&#46; Echocardiographic assessment before discharge revealed good biventricular function with no segmental changes of ventricular function&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was discharged six days after CABG&#44; medicated with aspirin 4&#46;3 mg&#47;kg once daily&#44; propranolol 10 mg three times daily&#44; furosemide 10 mg twice daily and warfarin with target international normalized ratio 2-2&#46;5&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">At the time of this report the patient was asymptomatic&#44; with no electrocardiographic&#44; echocardiographic or clinical signs of ischemia&#46; Coronary computed tomography angiography two years after surgery revealed patency of the graft with good distal perfusion of the LAD &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">According to Yuan&#39;s review of 637 patients with KD who underwent cardiac surgery between 1990 and 2011&#44; the disease has a male-to-female ratio of 3&#46;1&#58;1&#46; The mean age of onset was 4&#177;3&#46;6 years&#44; the mean age at time of surgery was 13&#46;3&#177;11&#46;1 years and the interval between onset and surgical procedure was 9&#46;5&#177;9&#46;4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In this review&#44; myocardial infarction occurred in 28&#46;9&#37; of cases&#44; the inferior wall being the most common region of infarction &#40;40&#46;8&#37;&#41;&#46; The most common coronary changes found were stenosis&#44; total occlusion and CAA&#46; The most reported intervention was CABG under standard cardiopulmonary bypass&#44; with a mean of 1&#46;67&#177;0&#46;8 grafts per patient&#44; LIMA to LAD being the most commonly used bypass graft&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Management of the cardiac sequelae of KD consists&#44; on the one hand&#44; of prevention and treatment strategies for coronary thrombosis and myocardial infarction and&#44; on the other hand&#44; coronary revascularization procedures when appropriate&#44; to relieve angina and diminish the risk of myocardial infarction and sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Thrombus formation can easily develop in spite of anticoagulation therapy&#44; and the risk of myocardial infarction and sudden death persists even if correct medical therapy is established&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In addition&#44; coronary aneurysms with an internal diameter &#62;8 mm or with a z-score &#8805;10 are associated with a higher risk of cardiac events&#44; making coronary revascularization procedures an important issue&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">KD represents a challenge as far as percutaneous coronary intervention &#40;PCI&#41; is concerned&#44; as low body weight and severely calcified coronary arteries often lead to failure of stent implantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7&#44;10</span></a> Although PCI has been used with success is some cases&#44; CABG appears to be more efficacious&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Evidence regarding coronary revascularization procedures in this population is limited&#44; as it is derived from expert consensus&#44; retrospective reviews and data from the adult population with coronary artery disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">According to the Research Committee of the Japanese Ministry of Health&#44; Labor and Welfare&#44; CABG should be the revascularization procedure of choice for patients with severe left ventricular dysfunction or presenting multiple&#44; ostial or long-segment coronary lesions&#46; The American Heart Association guidelines state that CABG should be considered when reversible ischemia is present on stress-imaging test results&#44; perfusing the myocardium through the graft is still viable&#44; and no appreciable lesions are present in the artery distal to the planned graft site&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In addition&#44; these guidelines&#44; list as potential indications for CABG&#44; severe occlusion of the left main coronary artery&#44; severe occlusion of the proximal segment of the LAD&#44; severe occlusion of more than one major coronary artery&#44; and recurrent myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Internal mammary grafts grow with the child&#39;s somatic growth and have additional benefits in terms of endothelial function&#44; and are therefore the conduit of choice for these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;10&#44;11</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Arterial grafts in KD patients have been associated with patency rates of 94&#37;&#44; 82&#37;&#44; and 78&#37; at one&#44; five&#44; and 10 years&#44; respectively&#59; and freedom from cardiac events was 70 at 10 years&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">This case report stresses the importance of early diagnosis and correct management of KD in order to avoid late cardiac sequelae&#44; but also highlights the importance of systematic follow-up and parental education in order to detect coronary lesions that can lead to an adverse prognosis&#46; Treatment with IVIG within 10 days of fever onset&#44; which is associated with a five-fold reduction in CAA&#44; is of great importance&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;3&#44;8</span></a> This treatment was not feasible in the present case due to the late diagnosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">When performed by an experienced surgeon&#44; CABG is a reliable treatment option for patients who present with coronary sequelae from KD&#44; even at a very young age&#46; As the inflammatory nature of KD is different from the pathophysiology commonly associated with atherosclerotic heart disease&#44; prognostic considerations cannot be extrapolated from the adult coronary population&#46; Further studies with longer follow-up will eventually enable recommendations to be made regarding conduit selection&#44; myocardial revascularization methods and long-term prognosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kawasaki disease &#40;KD&#41; with cardiac involvement can result in the development of coronary aneurysm&#44; stenosis or thrombosis with significant cardiovascular implications&#46; We report the case of a 23-month-old male with a late diagnosis of KD&#44; in whom intravenous immunoglobulin treatment was not feasible&#46; The patient&#39;s course was assessed by routine echocardiography&#46; At the age of five years&#44; angiographic assessment revealed an aneurysm of the anterior descending coronary artery measuring 17 mm&#215;7 mm involving the first diagonal branch&#44; 90&#37; post-aneurysmal stenosis&#44; and an aneurysm of the right coronary artery measuring 32 mm&#215;6 mm&#46; Due to the critical anatomy of the anterior descending artery the revascularization method of choice was coronary artery bypass surgery with an internal mammary artery graft&#44; under cardiopulmonary bypass&#46; There were no significant intraoperative or postoperative complications&#46; This confirms coronary artery bypass grafting as a reliable treatment option for patients who present with coronary sequelae from KD&#44; even at a very young age&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A doen&#231;a de Kawasaki pode resultar no desenvolvimento de aneurisma&#44; estenose e trombose coron&#225;ria com importantes implica&#231;&#245;es cardiovasculares&#46; Reportamos o caso de um doente do sexo masculino de 23 meses com o diagn&#243;stico tardio de doen&#231;a de Kawasaki&#44; impossibilitando o tratamento atempado com imunoglobulina endovenosa&#46; O doente foi seguido em ambulat&#243;rio com controlo ecocardiogr&#225;fico e angiogr&#225;fico&#46; Aos cinco anos de idade a coronariografia revelava&#58; a&#41; aneurisma da art&#233;ria descendente anterior com 17&#215;7 mm&#44; envolvendo a primeira diagonal&#59; b&#41; estenose de 90&#37; p&#243;s-aneurism&#225;tica&#58; c&#41; aneurisma da coron&#225;ria direita com 32&#215;6 mm&#46; Tendo em considera&#231;&#227;o a anatomia cr&#237;tica da les&#227;o envolvendo a art&#233;ria descendente anterior&#44; a estrat&#233;gia de interven&#231;&#227;o escolhida foi cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica com um enxerto de art&#233;ria mam&#225;ria esquerda <span class="elsevierStyleItalic">in situ</span>&#44; sob circula&#231;&#227;o extracorporal&#46; O procedimento decorreu sem intercorr&#234;ncias intra ou p&#243;s-operat&#243;rias de relevo&#46; A cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica apresenta-se como uma op&#231;&#227;o vi&#225;vel na presen&#231;a de sequelas coron&#225;rias de doen&#231;a de Kawasaki&#44; mesmo em doentes muito jovens&#46;</p></span>"
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                          "etal" => true
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                          "etal" => true
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Case report
Coronary artery bypass grafting in a child with Kawasaki disease
Cirurgia de revascularização miocárdica numa criança com doença de Kawasaki
Pedro Magroa,
Autor para correspondência
pedromagro@gmail.com

Corresponding author.
, Nuno Carvalhob, Rui Anjosb, José Nevesa
a Department of Cardiothoracic Surgery, Santa Cruz Hospital, Carnaxide, Portugal
b Department of Pediatric Cardiology, Santa Cruz Hospital, Carnaxide, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Kawasaki disease &#40;KD&#41;&#44; also known as mucocutaneous lymph node syndrome&#44; is a vasculitis of unknown etiology first described by Tomisaku Kawasaki in 1961&#44; in Japan&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Its incidence in Portugal is estimated at six per 100 000 children under five years of age&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> which is comparable to the range reported in other European studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the acute phase its clinical features include fever&#44; typical changes in the mucous membranes&#44; edema and desquamation of the extremities&#44; polymorphous rash and cervical adenopathies&#46; However&#44; the major morbidity associated with KD is cardiac involvement due to vasculitis of medium-sized vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Coronary artery aneurysm &#40;CAA&#41; is the classic KD-related complication&#46; CAA occurs in 15-25&#37; of untreated patients<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;5&#8211;7</span></a> and can be demonstrated by echocardiography as soon as seven days after fever onset&#46; Formation of CAAs is most common in the proximal left anterior descending artery &#40;LAD&#41; and the proximal right coronary artery &#40;RCA&#41;&#44; especially at branch points&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Approximately half of CAAs regress to normal lumen diameter within two years of illness onset&#46; The likelihood of regression is inversely proportional to the diameter of the aneurysm&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> CAAs in patients with onset in infancy&#44; proximal location&#44; or saccular form&#44; are also less likely to regress&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;6&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Persistent CAAs are prone to the development of stenosis&#44; tortuosity&#44; calcification and thrombosis&#59; they can be responsible for myocardial infarction &#40;&#60;5&#37;&#41; and death &#40;1-5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;7&#8211;9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 23-month-old male presented at his local hospital with desquamation of the extremities&#44; two weeks after onset of fever&#44; cervical adenopathies&#44; strawberry tongue&#44; conjunctivitis and cheilitis&#46; He had a three-year-old half-brother with surgically corrected complex congenital heart disease&#46; No other significant family or personal medical history was present&#46; He was diagnosed with KD associated with large aneurysms and treated with aspirin&#46; Due to the late diagnosis&#44; intravenous immunoglobulin &#40;IVIG&#41; was not given at the time of diagnosis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">After completing nine months of dual antithrombotic therapy with low-dose aspirin and clopidogrel&#44; the patient was assessed by diagnostic coronary angiography&#44; which identified CAAs of the proximal LAD measuring 22 mm&#215;8 mm and of the proximal RCA measuring 25 mm&#215;6 mm&#46; He was then started on warfarin and monitored with regular echocardiographic assessment&#46; No change in CAA measurements was documented in the subsequent echocardiographic exams or by repeat coronary angiography one year later&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At five years of age&#44; weighing 23&#46;1 kg and measuring 116 cm&#44; the patient was re-catheterized and progression of the previously documented lesions was noted&#46; He was asymptomatic&#46; Physical examination was unremarkable&#46; Coronary angiography showed a CAA of the LAD measuring 17 mm&#215;7 mm involving the first diagonal branch associated with a 90&#37; post-aneurysmal stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; and a CAA of the RCA measuring 32 mm&#215;6 mm&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was admitted and myocardial revascularization was proposed&#46; As ostial and long-segment lesions of important coronary arteries had been documented&#44; coronary artery bypass grafting &#40;CABG&#41; was the procedure of choice&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgery was performed under general anesthesia&#46; A standard median sternotomy was performed and the left internal mammary artery &#40;LIMA&#41; was harvested&#46; After administration of full-dose heparin&#44; cardiac bypass was established by cannulation of the ascending aorta &#40;16 Fr Medtronic DLP cannula&#41; and the right atrial appendage &#40;28 Fr Medtronic DLP&#41;&#46; Anastomosis of the pediculated&#44; non-skeletonized LIMA to the proximal LAD was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41; in the usual manner with an 8-0 polypropylene suture&#44; after ascending aortic clamping and anterograde administration of cold cardioplegic solution&#46; Intraoperative findings consisted of a LIMA with a diameter of 1&#46;5 mm and very good pulsatile flow and a LAD without signs of degeneration&#44; inflammation or calcification&#44; and a diameter of approximately 1 mm distal to the aneurysm&#46; Total bypass time was 28 minutes and total ischemic time was 14 minutes&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The postoperative period was uneventful&#46; Echocardiographic assessment before discharge revealed good biventricular function with no segmental changes of ventricular function&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was discharged six days after CABG&#44; medicated with aspirin 4&#46;3 mg&#47;kg once daily&#44; propranolol 10 mg three times daily&#44; furosemide 10 mg twice daily and warfarin with target international normalized ratio 2-2&#46;5&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">At the time of this report the patient was asymptomatic&#44; with no electrocardiographic&#44; echocardiographic or clinical signs of ischemia&#46; Coronary computed tomography angiography two years after surgery revealed patency of the graft with good distal perfusion of the LAD &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">According to Yuan&#39;s review of 637 patients with KD who underwent cardiac surgery between 1990 and 2011&#44; the disease has a male-to-female ratio of 3&#46;1&#58;1&#46; The mean age of onset was 4&#177;3&#46;6 years&#44; the mean age at time of surgery was 13&#46;3&#177;11&#46;1 years and the interval between onset and surgical procedure was 9&#46;5&#177;9&#46;4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In this review&#44; myocardial infarction occurred in 28&#46;9&#37; of cases&#44; the inferior wall being the most common region of infarction &#40;40&#46;8&#37;&#41;&#46; The most common coronary changes found were stenosis&#44; total occlusion and CAA&#46; The most reported intervention was CABG under standard cardiopulmonary bypass&#44; with a mean of 1&#46;67&#177;0&#46;8 grafts per patient&#44; LIMA to LAD being the most commonly used bypass graft&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Management of the cardiac sequelae of KD consists&#44; on the one hand&#44; of prevention and treatment strategies for coronary thrombosis and myocardial infarction and&#44; on the other hand&#44; coronary revascularization procedures when appropriate&#44; to relieve angina and diminish the risk of myocardial infarction and sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Thrombus formation can easily develop in spite of anticoagulation therapy&#44; and the risk of myocardial infarction and sudden death persists even if correct medical therapy is established&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In addition&#44; coronary aneurysms with an internal diameter &#62;8 mm or with a z-score &#8805;10 are associated with a higher risk of cardiac events&#44; making coronary revascularization procedures an important issue&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">KD represents a challenge as far as percutaneous coronary intervention &#40;PCI&#41; is concerned&#44; as low body weight and severely calcified coronary arteries often lead to failure of stent implantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7&#44;10</span></a> Although PCI has been used with success is some cases&#44; CABG appears to be more efficacious&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Evidence regarding coronary revascularization procedures in this population is limited&#44; as it is derived from expert consensus&#44; retrospective reviews and data from the adult population with coronary artery disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">According to the Research Committee of the Japanese Ministry of Health&#44; Labor and Welfare&#44; CABG should be the revascularization procedure of choice for patients with severe left ventricular dysfunction or presenting multiple&#44; ostial or long-segment coronary lesions&#46; The American Heart Association guidelines state that CABG should be considered when reversible ischemia is present on stress-imaging test results&#44; perfusing the myocardium through the graft is still viable&#44; and no appreciable lesions are present in the artery distal to the planned graft site&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In addition&#44; these guidelines&#44; list as potential indications for CABG&#44; severe occlusion of the left main coronary artery&#44; severe occlusion of the proximal segment of the LAD&#44; severe occlusion of more than one major coronary artery&#44; and recurrent myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Internal mammary grafts grow with the child&#39;s somatic growth and have additional benefits in terms of endothelial function&#44; and are therefore the conduit of choice for these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;10&#44;11</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Arterial grafts in KD patients have been associated with patency rates of 94&#37;&#44; 82&#37;&#44; and 78&#37; at one&#44; five&#44; and 10 years&#44; respectively&#59; and freedom from cardiac events was 70 at 10 years&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">This case report stresses the importance of early diagnosis and correct management of KD in order to avoid late cardiac sequelae&#44; but also highlights the importance of systematic follow-up and parental education in order to detect coronary lesions that can lead to an adverse prognosis&#46; Treatment with IVIG within 10 days of fever onset&#44; which is associated with a five-fold reduction in CAA&#44; is of great importance&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2&#44;3&#44;8</span></a> This treatment was not feasible in the present case due to the late diagnosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">When performed by an experienced surgeon&#44; CABG is a reliable treatment option for patients who present with coronary sequelae from KD&#44; even at a very young age&#46; As the inflammatory nature of KD is different from the pathophysiology commonly associated with atherosclerotic heart disease&#44; prognostic considerations cannot be extrapolated from the adult coronary population&#46; Further studies with longer follow-up will eventually enable recommendations to be made regarding conduit selection&#44; myocardial revascularization methods and long-term prognosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kawasaki disease &#40;KD&#41; with cardiac involvement can result in the development of coronary aneurysm&#44; stenosis or thrombosis with significant cardiovascular implications&#46; We report the case of a 23-month-old male with a late diagnosis of KD&#44; in whom intravenous immunoglobulin treatment was not feasible&#46; The patient&#39;s course was assessed by routine echocardiography&#46; At the age of five years&#44; angiographic assessment revealed an aneurysm of the anterior descending coronary artery measuring 17 mm&#215;7 mm involving the first diagonal branch&#44; 90&#37; post-aneurysmal stenosis&#44; and an aneurysm of the right coronary artery measuring 32 mm&#215;6 mm&#46; Due to the critical anatomy of the anterior descending artery the revascularization method of choice was coronary artery bypass surgery with an internal mammary artery graft&#44; under cardiopulmonary bypass&#46; There were no significant intraoperative or postoperative complications&#46; This confirms coronary artery bypass grafting as a reliable treatment option for patients who present with coronary sequelae from KD&#44; even at a very young age&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A doen&#231;a de Kawasaki pode resultar no desenvolvimento de aneurisma&#44; estenose e trombose coron&#225;ria com importantes implica&#231;&#245;es cardiovasculares&#46; Reportamos o caso de um doente do sexo masculino de 23 meses com o diagn&#243;stico tardio de doen&#231;a de Kawasaki&#44; impossibilitando o tratamento atempado com imunoglobulina endovenosa&#46; O doente foi seguido em ambulat&#243;rio com controlo ecocardiogr&#225;fico e angiogr&#225;fico&#46; Aos cinco anos de idade a coronariografia revelava&#58; a&#41; aneurisma da art&#233;ria descendente anterior com 17&#215;7 mm&#44; envolvendo a primeira diagonal&#59; b&#41; estenose de 90&#37; p&#243;s-aneurism&#225;tica&#58; c&#41; aneurisma da coron&#225;ria direita com 32&#215;6 mm&#46; Tendo em considera&#231;&#227;o a anatomia cr&#237;tica da les&#227;o envolvendo a art&#233;ria descendente anterior&#44; a estrat&#233;gia de interven&#231;&#227;o escolhida foi cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica com um enxerto de art&#233;ria mam&#225;ria esquerda <span class="elsevierStyleItalic">in situ</span>&#44; sob circula&#231;&#227;o extracorporal&#46; O procedimento decorreu sem intercorr&#234;ncias intra ou p&#243;s-operat&#243;rias de relevo&#46; A cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica apresenta-se como uma op&#231;&#227;o vi&#225;vel na presen&#231;a de sequelas coron&#225;rias de doen&#231;a de Kawasaki&#44; mesmo em doentes muito jovens&#46;</p></span>"
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                      "titulo" => "Coronary insufficiency in children&#58; review of literature and report of a rare case with unknown aetiology"
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                          "etal" => true
                          "autores" => array:3 [
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                            2 => "A&#46;A&#46; Assal"
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                        "volumen" => "22"
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                      "titulo" => "Twelve years of kawasaki disease in Portugal&#58; epidemiology in hospitalized children"
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