arrhythmias, or poor exercise tolerance (less than 3 metabolic equivalents) because of symptoms such as angina or dyspnea.2 In those with angina but without these high-risk characteristics, treatment with medical management alone versus percutaneous revascularization seems to result in similar long-term morbidity and rates of myocardial infarction However, patients with symptoms refractory to maximal medical management and those with silent ischemia involving more than 10% of the myocardium do benefit from revascularization.173 Prior recommendations had included revascularization for patients with stenosis greater than 70% on coronary angiography174; however, recent studies have shown no benefit in stable patients from revascularization based on lesion severity alone Patients with significant stenosis should have fractional flow reserve testing; those with a ratio below 0.80 likely benefit from intervention.175 For patients who require revascularization, the decision regarding surgery or a percutaneous procedure requires careful balancing of risks and benefits Coronary artery bypass surgery is usually preferred for patients with left main coronary involvement, multivessel coronary involvement, and/or reduced left ventricular function because more complete revascularization can be achieved (Videos 52.6 and 52.7).176 Coronary artery bypass grafting is also preferred in older children and adults, but even young children have had successful surgical management The procedure has a low mortality and morbidity rate of approximately 1% to 2%.2,177 The use of internal mammary arteries is favored because of their increased patency on long-term follow-up and their continued growth during childhood The patency rates for mammary artery grafts at 1, 5, and 15 years were 95%, 91%, and 91%, respectively, in children above 12 years of age at the time of the procedure.178 Younger patients had lower patency rates of 93%, 73%, and 65% Saphenous vein patency was significantly lower, at 65%, 53%, and 48% Physiologic assessment of stenosis is especially important prior to contemplating revascularization because mammary artery grafts may fail to mature owing to competitive flow from the native circulation Percutaneous transluminal balloon angioplasty for anastomotic stenosis after bypass grafting improves the long-term patency in small children to rates resembling those in older children.176 Percutaneous coronary intervention is usually best performed by cardiologists who typically treat adults It is favored in patients with single-vessel disease and multivessel disease involving focal and easily treated lesions as well as normal left ventricular function It can also be considered in patients with significant comorbidities—which make the risk of coronary artery bypass grafting very high —provided that the lesions are amenable to percutaneous intervention Possible interventions include percutaneous transluminal coronary angioplasty, rotational atherectomy, and the placement of stents.174 Balloon angioplasty as a standalone technique for the treatment of stenotic lesions in Kawasaki disease is suboptimal owing to heavily fibrotic and calcific lesions that are extremely difficult to expand The early success rate of percutaneous intervention is approximately 86% However, the high pressures required to expand coronary lesions in Kawasaki disease have been associated with the development of neoaneurysms in some 7% of cases Rotational atherectomy should be considered in patients with severely calcified lesions; its use increases the success rate to about 96% Whichever technique is used, coronary stenting should be considered to decrease the impact of recoil on restenosis Following percutaneous revascularization in a small number of children with Kawasaki disease, stenosis recurred in about 29% of segments with angioplasty, approximately 28% of segments with rotational atherectomy, and approximately 8% of segments with stent placement,179 with up to 60% of patients requiring reintervention.180 Both bare metal stents and drug-eluting stents have been used, with bare metal stents posing a higher risk of in-stent restenosis However, drugeluting stents take longer to endothelialize, and dual antiplatelet therapy is required for 1 year as opposed to only 1 month Thus the patient's risk of bleeding should be considered in the choice of stent Intravascular imaging can be helpful in planning and guiding percutaneous procedures in patients with Kawasaki disease Cardiac transplantation can be performed in children with Kawasaki disease who have end-stage ischemic cardiomyopathy and in whom severe coronary artery lesions cannot be treated further with interventional catheterization or coronary artery bypass procedures.181 Nursing Care of the Patient With Kawasaki Disease Nurses play an important role in diagnosis, treatment, and education both during and after an episode of Kawasaki disease In addition, nurses can facilitate communication between the various clinical specialties and the parents During the child's initial evaluation and hospitalization, nursing priorities are focused on assessment of the patient as well as providing pharmacologic treatment and supportive care for the child In addition, individualized teaching is very important for the family during hospitalization and prior to the child's discharge On a longer-term basis, children with coronary artery aneurysms require regular monitoring, management, and continuing education about their condition In Kawasaki disease, all patients present to the hospital with a history of fever By the time a child is evaluated in an emergency department, he or she may be dehydrated Laboratory work is obtained in the emergency department and an intravenous line is placed Fluid status is assessed and intravenous fluids are provided if necessary A baseline echocardiogram is performed at the time of diagnosis to visualize the coronary arteries and provide a baseline measurement to compare with subsequent studies For younger children (below 2.5 or 3 years old), this test may require sedation and the nurse will need to assist, assuring that appropriate guidelines regarding oral intake are followed As stated earlier, the initial treatment of Kawasaki disease includes the administration of IVIG, which provides a large fluid load Thus close hemodynamic monitoring is essential during infusion The myocarditis seen in Kawasaki disease is typically subclinical, but children will rarely present with signs of cardiogenic shock and require support in the intensive care unit Fluid replacement and fluid status should be monitored carefully, with accurate assessment of intake and output and monitoring for signs of congestive heart failure Serum albumin may be low in this illness and may contribute to increased capillary permeability and edema If the child develops signs of congestive heart failure during the administration of IVIG, furosemide and/or intravenous albumin may be indicated During the immunoglobulin infusion, some children have significant elevations in temperature, tachycardia, rigors, and hypotension Premedication diphenhydramine (Benadryl 1 mg/kg) prior to immunoglobulin infusion may be given to help decrease reactions