Szatkowski Arie, Ndubuka-Irobunda Christopher, Oesterle Stephen N, Burkhoff Daniel
Department of Medicine, Division of Circulatory Physiology, Columbia University, New York, New York 10032, USA.
Am J Cardiovasc Drugs. 2002;2(4):255-66. doi: 10.2165/00129784-200202040-00005.
Transmyocardial laser revascularization (TMR or TMLR) is a surgical therapy developed to treat patients with debilitating, medically refractory angina pectoris due to epicardial coronary artery disease that is not amenable to treatment using the traditional methods of percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). This technique can also be applied percutaneously [percutaneous myocardial revascularization (PMR) or direct myocardial revascularization (DMR)]. The original hypotheses which motivated development of TMR were that: (i) oxygenated blood could flow directly from the left ventricle and perfuse the myocardium; and (ii) such artificially created channels would remain patent. However, experimental data have refuted both hypotheses. In the face of early reports of marked clinical benefits in terms of relief of anginal symptoms, alternate hypotheses to explain the mechanism have been pursued, including TMR-associated neoangiogenesis and cardiac denervation. Clinically, numerous reports of reduction in frequency and severity of anginal symptoms, improved exercise tolerance and improved quality of life have appeared from nonblind registry-type studies as well as nonblind randomized clinical trials of TMR or PMR versus continued medical therapy. TMR was not associated with a significant improvement in survival compared with medical therapy alone in randomized trials. For example, the prospective, randomized Angina Treatments-Lasers and Normal Therapies in Comparison (ATLANTIC) trial found a 1-year mortality of 5% in 92 TMR-treated patients and 10% in 90 patients treated with medication only. No proof of improved myocardial blood flow in hearts of treated patients is currently available. The first randomized study of PMR was the Potential Angina Class Improvement From Intramyocardial Channels (PACIFIC) trial which found significantly greater improvements in anginal symptoms and exercise tolerance with PMR plus medical therapy, compared with medical therapy alone. The preliminary results of two double-blind studies with PMR/DMR have been presented but have not yet been published in full. Whereas PMR-treated patients did significantly better than sham-treated control groups after 6 months in the Blinded Evaluation of Laser Intervention Electively For angina pectoris (BELIEF) trial, there was no difference after 1 year between DMR-treated patients and those treated with medication only in the DMR In Regeneration of Endomyocardial Channels Trial (DIRECT). Different devices used for revascularization in these two trials may explain the disparity in the results, and therefore the efficacy and tolerability of each device should be judged upon data collected with that particular device.
经心肌激光血运重建术（TMR 或 TMLR）是一种外科治疗方法，用于治疗因心外膜冠状动脉疾病导致的严重、药物难治性心绞痛患者，这些患者无法通过传统的经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）进行治疗。该技术也可经皮应用[经皮心肌血运重建术（PMR）或直接心肌血运重建术（DMR）]。推动 TMR 发展的最初假设是：（i）含氧血液可直接从左心室流出并灌注心肌；（ii）这种人工创建的通道将保持通畅。然而，实验数据驳斥了这两个假设。面对早期关于缓解心绞痛症状有显著临床益处的报道，人们一直在寻求其他假设来解释其机制，包括与 TMR 相关的新生血管形成和心脏去神经支配。临床上，非盲登记型研究以及 TMR 或 PMR 与持续药物治疗对比的非盲随机临床试验都有大量关于心绞痛症状频率和严重程度降低、运动耐量提高以及生活质量改善的报道。在随机试验中，与单纯药物治疗相比，TMR 并未使生存率有显著提高。例如，前瞻性随机对照试验“心绞痛治疗——激光与常规疗法比较”（ATLANTIC）发现，92 例接受 TMR 治疗的患者 1 年死亡率为 5%，90 例仅接受药物治疗的患者死亡率为 10%。目前尚无证据表明接受治疗的患者心肌血流得到改善。PMR 的首个随机研究是“心肌内通道改善潜在心绞痛分级”（PACIFIC）试验，该试验发现与单纯药物治疗相比，PMR 联合药物治疗在心绞痛症状和运动耐量方面有显著更大的改善。两项关于 PMR/DMR 的双盲研究的初步结果已公布，但尚未全文发表。在“心绞痛激光干预的盲法评估”（BELIEF）试验中，6 个月后接受 PMR 治疗的患者明显优于假手术对照组，但在“心肌内膜通道再生的 DMR 试验”（DIRECT）中，1 年后接受 DMR 治疗的患者与仅接受药物治疗的患者之间没有差异。这两项试验中用于血运重建的不同设备可能解释了结果的差异，因此每种设备的疗效和耐受性应根据使用该特定设备收集的数据来判断。
