==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 10.5144/0256-4947.2008.307asm-4-307LettersOff-pump beating coronary artery bypass grafting in a young adult with Kawasaki disease Hsu Kuo-Feng Hung Kuo-Chun Tsai Yi-Ting Lin Chih-Yuan Li Chung-Yi Tsai Chien-Sung Department of Surgery, Division of Cardiovascular Surgery, Tri-Service General Hospital, No. 325, Cheng-Kung Rd, Sec 2, Taipei 114, Taiwan, T: 886-2-8792-3311 #19556, F: 886-2-8792-7168, hsukf97@yahoo.com.twJul-Aug 2008 28 4 307 308 Copyright © 2008, Annals of Saudi Medicine2008This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. ==== Body To the Editor: Atherosclerosis is a well-known cause of coronary artery disease (CAD). Risk factors, including hypertension, hyperlipidemia and hyperglycemia, are well established. Kawasaki disease is a risk factor for the development of coronary artery aneurysm and stenosis in most infants and children but surgical revascularization for coronary artery lesions caused by Kawasaki disease has been rarely reported in adult patients. Kawasaki disease plays an important role in ischemic heart disease in adults without coronary risk factors. We encountered a young adult male with Kawasaki disease who underwent off-pump beating coronary artery bypass grafting (OPB-CABG). A 35-year-old man with a history of mucocutaneous lymph node syndrome (Kawasaki disease) in childhood presented with chest tightness accompanied with shortness of breath for 6 months. He had no family history of atherosclerotic disease or associated risk factors such as smoking, hypertension and hyperlipidemia. There were no abnormalities in the physical examination or laboratory data. An electrocardiogram showed ST-segment depression and T wave inversion in leads V5 and V6. Treadmill-exercise testing revealed a high probability of CAD. The transthoracic echocardiography showed hypokinesia to akinesia of the proximal inferior wall and an estimated ejection fraction of 43%. Coronary angiography showed ectasis of the left main and diffuse ectasia of the left anterior descending artery (LADA) with proximal to distal diffuse segmental eccentric stenosis estimated to be about 50% to 60%. Angiography also showed a 95% discrete eccentric stenosis at the ostium of the first diagonal branch (Figures 1, 2) and diffuse ectasia at the proximal portion of the circumflex coronary artery with total occlusion at the middle portion (Figure 3) and diffuse ectasia at the proximal portion of the right coronary artery with total occlusion at the middle portion (Figure 4). CAD with a three-vessel aneurysm component was diagnosed, which is the appearance typically seen in Kawasaki disease. Percutaneous transluminal coronary angioplasty (PTCA) failed for the right coronary artery and left circumflex artery lesions. The patient underwent surgical revascularization by OPB-CABG with four-vessels grafts: left internal mammary artery to LADA, greater saphenous grafting vein to the secondary diagonal branch, distal left circumflex coronary artery, and secondary obtuse marginal. The postoperative course was uneventful and he had no further cardiac events at 2 years follow-up. Kawasaki disease is a syndrome that involves the skin, mouth, and lymph nodes. The outcome varies from complete recovery to fatal complications of coronary artery involvement. 1 Development of aneurysms and occlusive lesions in Kawasaki disease, particularly in children, have been well documented.2 By spontaneous regression of coronary complications in Kawasaki disease, adult ischemic heart disease secondary to Kawasaki disease is uncommon. In adults, CAD is usually related to multiple predisposing factors, such as hyperlipidemia, cigarette smoking, diabetes mellitus, hypertension, strong family history, and others. However, in the absence of such risk factors, Kawasaki disease should be considered a cause of coronary artery lesions. In pediatric Kawasaki disease patients with coronary artery occlusive disease, anti-angina drugs and coronary angioplasty are often used as effective treatment.3 For PTCA failure or multiple coronary artery stenosis cases, CABG using arterial grafts can provide good results in long-term clinical follow-up.4 Kato reported 9 of 21 adult patients with a definite or suspected history of Kawasaki disease who underwent CABG and there are other case reports.5–8 In a review, clinical symptoms were described as acute myocardial infarction (MI) or previous MI or angina pectoris and the patients received conservative medical treatment, angioplasty, or surgical intervention in the form of CABG.9 Good results were reported for the CABG group while medication or PTCA has failed. Thus, CABG may be preferable in adult patients with Kawasaki disease as well as in adults with atherosclerotic ischemic heart disease. OPB-CABG is as effective as traditional CABG in the CAD patient.10 We adopted the off-pump beating technique for multiple arterial grafts and successfully treated our CAD adult patient with Kawasaki disease. Long-term follow-up is necessary to compare the new technique and traditional CABG. Figure 1 Coronary angiography showing severe coronary artery disease with several aneurysms and stenoses (arrow). Figure 2 Aneurysmal left anterior descending artery and 95% ostium stenosis of the first diagonal branch. Figure 3 Proximal ectasia and total occlusion of the middle portion of the circumflex coronary artery (arrow). Figure 4 Proximal ectasia and total occlusion of the middle portion of the right coronary artery (arrow). ==== Refs REFERENCES 1 Gupta-Malhotra M Rao PS Current perspectives on Kawasaki disease Indian J Pediatr 205 72 621 629 2 Kato H Ichinose E Yoshioka F Takechi T Matsunaga S Suzuki K Fate of coronary aneurysms in Kawasaki disease: serial coronary angiography and long-term follow-up study Am J Cardiol 1982 49 1758 1766 7081062 3 Ino T Akimoto K Ohkubo M Nishimoto K Yabuta K Takaya J Application of Percutaneous transluminal coronary angioplasty to coronary arterial stenosis in Kawasaki disease Circulation 1996 93 1709 1715 8653877 4 Yoshikawa Y Yagihara T Kameda Y Taniguchi S Tsuda E Kawahira Y Result of surgical treatments in patients with coronary-arterial obstructive disease after Kawasaki disease Eur J Cardiothorac Surg 2000 17 515 519 10814912 5 Kato H Inoue O Kawasaki T Fujiwara H Watanabe T Toshima H Adult coronary artery disease probably due to childhood Kawasaki disease Lancet 1992 340 1127 1129 1359212 6 Ishiwata S Fuse K Nishiyama S Nakanishi S Watanabe Y Seki A Adult coronary artery disease secondary to Kawasaki disease in childhood Am J Cardiol 1992 69 692 694 1536122 7 Sato T Isomura T Hayashida N Aoyagi S Coronary artery revascularization in an adult with coronary aneurysms probably secondary to childhood Kawasaki disease Eur J Cardio-thorac Surg 1997 12 312 314 8 Bey M Chenik S Thameur H Baccar H Belhani A Coronary bypass in an adult with Kawasaki disease Heart Surg Forum 2004 7 E128 129 15138088 9 Garcia-Moll X Bardaji A Alonso J Bueno H Ischemic heart disease: 2006 update Rev Esp Cardiol 2007 60 Suppl 1 3 18 17352852 10 Murphy GJ Ascione R Angelini GD Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade? 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