基于超声心动图评估儿童川崎病冠状动脉异常的方法分析

doi:10.12372/jcp.2022.21e1282

摘要/Abstract

摘要：

目的对评估川崎病（KD）合并冠状动脉病变的4种超声心动图方法进行分析,为临床实现早期精准评估提供依据。方法以2017年12月至2020年7月于心内科住院治疗的KD合并冠状动脉病变患儿为研究对象,比较Kobayashi、Dallaire、Olivieri 3种冠状动脉Z值计算公式及国内1988年冠状动脉评估标准对KD冠状动脉异常的评估结果。结果共纳入患儿94例,男59例、女35例,中位年龄18.1（7.3~31.7）月。4种冠状动脉病变评估方法对于右冠状动脉近段（pRCA）、左冠状动脉主干（LMCA）、左前降支（LAD）不同病变程度的评判差异均有统计学意义（P<0.01）。两两比较发现,Olivieri对于pRCA巨大冠状动脉瘤的检出率低于Dallaire;对于LMCA正常及仅扩张的评估中,Olivier方法的检出率高于其他3种方法,对于小型冠状动脉瘤,Olivier方法的检出率低于Kobayashi及国内1988年标准;对于LAD巨大冠状动脉瘤,Dallaire检出率高于Kobayashi和Olivieri方法,差异均有统计学意义（P<0.05）。Dallaire方法评估右冠状动脉（RCA）发现,仅测量pRCA将导致11.7%的患儿低估RCA病变的扩张程度,并有52.1% RCA中段（mRCA）、27.7%RCA远段（dRCA）病变被漏诊。在测量LAD中段的患儿中,仅依靠Z值评估LAD近段将漏诊30%的LAD中段异常患儿。结论为减少KD初期冠状动脉病变的漏诊,基于超声心动图评估KD合并冠状动脉病变时,应尽可能对4支冠状动脉的不同节段全程测量。对于RCA的近端及中远段建议采用Dallaire方法评估;对LAD中段建议采用大于相邻血管内径1.5倍比值的方法评估。

关键词: 超声心动图, 冠状动脉异常, 冠状动脉评估, 川崎病

Abstract:

Objective Four echocardiographic methods for assessing Kawasaki disease (KD) complicated with coronary artery abnormalities were analyzed to provide a basis for early accurate clinical assessment. Methods The KD children combined with coronary artery lesions who were hospitalized in the Department of Cardiology from December 2017 to July 2020 were selected as the study subjects. Three Z-value formulas (Kobayashi, Dallaire and Olivieri) and 1988 domestic standard were used to evaluate the coronary artery abnormalities caused by KD. Results A total of 94 patients (59 boys and 35 girls) were enrolled with a median age of 18.1 (7.3-31.7) months. There were statistically significant differences in the lesions degree evaluation of proximal right coronary artery (pRCA), left main coronary artery (LMCA) and left anterior descending artery (LAD) among the four coronary artery lesions assessment methods (P<0.01). The detection rate of large coronary aneurysms in pRCA by Olivieri method was significantly lower than that by Dallaire method (P<0.05). The detection rate of Olivier method was significantly higher than the other three methods in the evaluation of normal and only dilated LMCA (P<0.05). For small coronary aneurysms, the detection rate of Olivier method was significantly lower than Kobayashi method and domestic standard in 1988 (P<0.05). Dallaire's detection rate was significantly higher than Kobayashi's and Olivieri's for large coronary aneurysms of LAD (P<0.05). When evaluating the right coronary artery (RCA) using the Dallaire method, it was found that if the pRCA was measured alone, the extent of RCA lesion expansion in 11.7% of patients would be underestimate, as well as 52.1% of middle RCA lesions and 27.7% of distant RCA lesions would be missed. Among the children who measured the middle of LAD, 30% of the children with abnormal middle of LAD were missed by Z-value evaluation of the proximal LAD alone. Conclusions In order to reduce the misdiagnosis of coronary artery lesions at the early stage of KD, all the different segments of the 4 coronary arteries should be measured as much as possible by echocardiography. The proximal and distal segments of RCA should be evaluated by Dallaire method. The criterion of a dimension >1.5 times should be used for the middle of LAD. For the middle of LAD, a ratio greater than 1.5 times the diameter of the surrounding segments is recommended.

Key words: echocardiography, coronary artery anomalies, assessment of coronary artery, Kawasaki disease

孙蕊, 曹爱梅, 李晓惠, 袁越, 张明明, 李丹, 石琳. 基于超声心动图评估儿童川崎病冠状动脉异常的方法分析[J]. 临床儿科杂志, 2022, 40(9): 690-695.

SUN Rui, CAO Aimei, LI Xiaohui, YUAN Yue, ZHANG Mingming, LI Dan, SHI Lin. Analysis of echocardiographic assessment of coronary artery abnormalities in children with Kawasaki disease[J]. Journal of Clinical Pediatrics, 2022, 40(9): 690-695.

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参考文献 21

[1]	黄国英. 川崎病流行病学研究进展和思考[J]. 中国小儿急救医学, 2020, 27(9): 641-644.
[2]	中华医学会儿科学分会心血管学组, 中华儿科杂志编辑委员会. 川崎病冠状动脉病变的临床处理建议(2020年修订版)[J]. 中华儿科杂志, 2020, 58(10): 718-724.
[3]	Fukazawa R, Kobayashi J, Ayusawa M, et al. JCS/JSCS 2020 Guideline on Diagnosis and Management of Cardiovascular Sequelae in Kawasaki Disease[J]. Circ J, 2020, 84(8): 1348-1407. doi: 10.1253/circj.CJ-19-1094 pmid: 32641591
[4]	Kobayashi T, Fuse S, Sakamoto N, et al. A new Z score curve of the coronary arterial internal diameter using the Lambda-Mu-Sigma method in a pediatric population[J]. J Am Soc Echocardiogr, 2016, 29(8): 794-801. doi: 10.1016/j.echo.2016.03.017
[5]	Dallaire F, Dahdah N. New equations and a critical appraisal of coronary artery Z scores in healthy children[J]. J Am Soc Echocardiogr, 2011, 24(1): 60-74. doi: 10.1016/j.echo.2010.10.004
[6]	McCrindle BW, Li JS, Minich LL, et al. Coronary artery involvement in children with Kawasaki disease: risk factors from analysis of serial normalized measurements[J]. Circulation, 2007, 116(2): 174-179. pmid: 17576863
[7]	Olivieri L, Arling B, Friberg M, et al. Coronary artery Z score regression equations and calculators derived from a large heterogeneous population of children undergoing echocardiography[J]. J Am Soc Echocardiogr, 2009, 22(2): 159-164. doi: 10.1016/j.echo.2008.11.003
[8]	金虹, 梁翊常, 张新春. 正常儿童冠状动脉超声心动图研究[J]. 中华儿科杂志, 1988, 26(5): 257-259.
[9]	杜忠东. 川崎病[M]. 北京: 科学技术文献出版社, 2009: 134.
[10]	McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association[J]. Circulation, 2017, 135(17): e927-e999.
[11]	de La Harpe M, di Bernardo S, Hofer M, et al. Thirty years of Kawasaki disease: a single-center study at the University Hospital of Lausanne[J]. Front Pediatr, 2019, 7: 11. doi: 10.3389/fped.2019.00011
[12]	Ogata S, Tremoulet AH, Sato Y, et al. Coronary artery outcomes among children with Kawasaki disease in the United States and Japan[J]. Int J Cardiol, 2013, 168(4): 3825-3828. doi: 10.1016/j.ijcard.2013.06.027
[13]	Zeng Y, Zhang M, Ko S, et al. An update on cardiovascular risk factors after Kawasaki disease[J]. Front Cardiovasc Med, 2021, 8: 671198. doi: 10.3389/fcvm.2021.671198
[14]	de Zorzi A, Colan SD, Gauvreau K, et al. Coronary artery dimensions may be misclassified as normal in Kawasaki disease[J]. J Pediatr, 1998, 133(2): 254-258.
[15]	Kim SH, Kim JY, Kim GB, et al. Diagnosis of coronary artery abnormalities in patients with Kawasaki disease according to established guidelines and Z score formulas[J]. J Am Soc Echocardiogr, 2021, 34(6): 662-672. doi: 10.1016/j.echo.2021.01.002
[16]	Zhang YQ, Chen SB, Huang GY, et al. Coronary artery indexed diameter and z score regression equations in healthy Chinese Han children[J]. J Clin Ultrasound, 2015, 43(1): 39-46.
[17]	夏焙, 许娜, 何学智, 等. 儿童超声心动图冠状动脉正常参考值及临床意义[J]. 中华医学超声杂志(电子版), 2013, 10(1): 42-51.
[18]	郑淋, 杜忠东, 金兰中, 等. 超声心动图评价儿童冠状动脉内径正常参考值范围及其临床意义[J]. 中华儿科杂志, 2013, 51(5): 371-376.
[19]	Huang CY, Chiu NC, Huang FY, et al. Prediction of coronary artery aneurysms in children with Kawasaki disease before starting initial treatment[J]. Front Pediatr, 2021, 9: 748467. doi: 10.3389/fped.2021.748467
[20]	Dietz S M, Kuipers I M, Tacke C, et al. Giant aneurysms: a gender-specific complication of Kawasaki disease?[J]. J Cardiol, 2017, 70(4): 359-365.
[21]	Advani N, Sastroasmoro S, Ontoseno T, et al. Long-term outcome of coronary artery dilatation in Kawasaki disease[J]. Ann Pediatr Cardiol, 2018, 11(2): 125-129. doi: 10.4103/apc.APC_172_16 pmid: 29922008

冠脉病变部位	冠脉病变程度	Dallaire	Kobayashi	Olivieri	1988年标准	χ²值	P
pRCA	正常或仅扩张	34(36.2)	29(30.9)	45(47.9)	32(34.0)	24.12	0.004
	小瘤	22(23.4)	25(26.6)	30(31.9)	31(32.9)
	中瘤	25(26.6)	32(34.0)	18(19.1)	28(29.8)
	大瘤	13(13.8)	8(8.5)	1(1.1)¹⁾	3(3.2)
LMCA	正常或仅扩张	35(37.2)	31(33.0)	58(61.7)¹⁾²⁾	17(18.1)¹⁾³⁾	48.55	<0.001
	小瘤	41(43.6)	44(46.8)	26(27.7)²⁾	56(59.6)³⁾
	中瘤	14(14.9)	18(19.1)	10(10.6)	21(22.3)
	大瘤	4(4.3)	1(1.1)	0(0.0)	0(0.0)
LAD	正常或仅扩张	31(33.0)	36(38.3)	40(42.6)	-	22.00	0.001
	小瘤	31(33.0)	39(41.5)	39(41.5)	-
	中瘤	23(24.5)	19(20.2)	15(16.0)	-
	大瘤	9(9.6)	0(0.0)¹⁾	0(0.0)¹⁾	-
LCX	正常或仅扩张	57(60.6)	58(60.7)	-	-	3.24	0.356
	小瘤	27(28.7)	30(31.9)	-	-
	中瘤	7(7.4)	6(6.4)	-	-
	大瘤	3(3.2)	0(0.0)	-	-