Korkola S, Lachapelle K, Chiu R C
Division of Cardiothoracic Surgery, McGill University, Montreal, Quebec, Canada.
J Formos Med Assoc. 1999 May;98(5):301-8.
Transmyocardial revascularization (TMR) is a new surgical procedure aimed at increasing blood flow to the ischemic myocardium. It has been used for treatment of patients with end-stage coronary artery disease who are not candidates for conventional measures such as medication, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting. TMR involves creating transmural channels in the myocardium using lasers, in areas shown to be ischemic during preoperative testing. This procedure has shown promising results in clinical trials, but the mechanism of its efficacy remains largely unknown. TMR was originally developed as a means of supplying blood to the ventricular myocardium, directly through channels made in the wall of the ventricle. This was in an attempt to recreate the situation that exists in the reptilian heart, in which the myocardium is perfused directly from the ventricular chamber through a rich network of sinusoids that bathe the myocardial cells. However, the existence of a significant sinusoidal network in the human heart is doubtful. Whether the myocardium can be perfused directly via the TMR channels is controversial; it is becoming clear that other mechanisms such as angiogenesis are also at work. This review will use TMR as an example to illustrate how surgical practice and thinking can be based on theories that have little or no sound experimental evidence to support them. The importance of elucidating the valid scientific basis of surgical procedures in this modern era of evidence-based medicine will be emphasized.
经心肌血管重建术（TMR）是一种旨在增加缺血心肌血流量的新型外科手术。它已被用于治疗终末期冠状动脉疾病患者，这些患者不适合采用药物治疗、经皮腔内冠状动脉成形术和冠状动脉搭桥术等传统治疗措施。TMR包括在术前检查显示为缺血的心肌区域使用激光创建透壁通道。该手术在临床试验中已显示出有前景的结果，但其疗效机制在很大程度上仍不清楚。TMR最初是作为一种通过在心室壁上制造的通道直接为心室心肌供血的方法而开发的。这是为了重现爬行动物心脏中存在的情况，即心肌通过丰富的窦状隙网络直接从心室腔灌注，这些窦状隙为心肌细胞提供营养。然而，人类心脏中是否存在大量的窦状隙网络尚值得怀疑。心肌是否能通过TMR通道直接灌注存在争议；越来越清楚的是，其他机制如血管生成也在起作用。本综述将以TMR为例来说明外科实践和思维是如何基于几乎没有可靠实验证据支持的理论的。将强调在这个循证医学的现代时代阐明外科手术有效科学依据的重要性。
