Landolfo C K, Landolfo K P, Hughes G C, Coleman E R, Coleman R B, Lowe J E
Duke University Medical Center, Departments of Internal Medicine, Surgery, and Radiology, Division of Cardiology, Durham, NC 27710, USA.
Circulation. 1999 Nov 9;100(19 Suppl):II128-33. doi: 10.1161/01.cir.100.suppl_2.ii-128.
This study was conducted to examine the intermediate-term clinical outcomes in patients with refractory angina pectoris treated with transmyocardial laser revascularization (TMR) at our institution. TMR is an alternative surgical technique for the treatment of myocardial ischemia and angina pectoris not amenable to conventional percutaneous or surgical revascularization. Limited data exist evaluating the natural history and duration of clinical improvement in angina pectoris following TMR.
Thirty-four patients with severe coronary artery disease unsuitable for treatment with standard revascularization techniques underwent TMR in myocardial regions determined to be ischemic by preoperative SPECT (201)Tl perfusion imaging following dipyridamole stress. Patients were assessed postoperatively at 3, 6, and 12 months for clinical outcomes including death, myocardial infarction, functional class of angina pectoris, and hospitalizations for unstable angina. Myocardial perfusion imaging by (201)Tl scintigraphy was also assessed at these temporal end points. Overall mortality at 1 year was 14.7% (n=5). Nonfatal myocardial infarction occurred in 3 patients (8.8%). Among the patients with complete 12-month follow-up (n =27), mean anginal class improved from 3.5+/-0. 5 pre-TMR to 2.8+/-0.7 and 2.5+/-0.7 at 3 and 6 months, respectively, and 2.8+/-0.9 at 12 months. Overall improvement in angina pectoris was sustained at 1 year by at least one functional class in 50% of patients. Mean hospitalizations per year for unstable angina declined from 2.4+/-1.6 pre-TMR to 1.7+/-2.0 post-TMR (P=0.01). There was no significant improvement in perfusion by SPECT (201)Tl imaging at any temporal end point post-TMR.
Despite the lack of demonstrable improvement in perfusion by SPECT (201)Tl imaging, TMR improved the functional class of angina pectoris in patients with end stage coronary artery disease to a modest degree. Although the maximal benefit in symptoms occurred at 6 months post-TMR, mild sustained clinical improvement above baseline was evident in 50% of patients at 1 year.
本研究旨在探讨我院采用经皮激光心肌血运重建术（TMR）治疗顽固性心绞痛患者的中期临床疗效。TMR是一种替代手术技术，用于治疗心肌缺血和不适用于传统经皮或手术血运重建的心绞痛。现有数据有限，无法评估TMR术后心绞痛的自然病程和临床改善持续时间。
34例严重冠状动脉疾病患者因不适合采用标准血运重建技术治疗，在术前双嘧达莫负荷试验后通过SPECT（201）Tl灌注成像确定为缺血心肌区域接受了TMR治疗。术后3、6和12个月对患者进行评估，观察临床结局，包括死亡、心肌梗死、心绞痛功能分级以及因不稳定型心绞痛住院情况。在这些时间点也通过（201）Tl闪烁显像评估心肌灌注成像。1年时的总死亡率为14.7%（n = 5）。3例患者发生非致命性心肌梗死（8.8%）。在完成12个月随访的患者中（n = 27），平均心绞痛分级从TMR术前的3.5±0.5分别改善至术后3个月时的2.8±0.7、6个月时的2.5±0.7以及12个月时的2.8±0.9。50%的患者在1年时心绞痛总体改善至少持续一个功能分级。不稳定型心绞痛每年的平均住院次数从TMR术前的2.4±1.6降至术后的1.7±2.0（P = 0.01）。TMR术后任何时间点SPECT（201）Tl成像的灌注均无显著改善。
尽管SPECT（201）Tl成像显示灌注无明显改善，但TMR在一定程度上改善了终末期冠状动脉疾病患者的心绞痛功能分级。虽然症状的最大改善出现在TMR术后6个月，但50%的患者在1年时仍有轻度且持续的高于基线的临床改善。
