Galiñanes Manuel, Loubani Mahmoud, Sensky Penelope R, Hassouna Ashraf, Cherryman Graham R, Leverment Joseph N, Samani Nilesh J
Department of Integrative Human Cardiovascular Physiology and Cardiac Surgery, Glenfield Hospital, University of Leicester, United Kingdom.
Ann Thorac Surg. 2004 Jul;78(1):122-8. doi: 10.1016/j.athoracsur.2003.12.032.
Transmyocardial laser revascularization (TMR) is an effective treatment for relief of refractory angina. This benefit may be mediated by increase in myocardial perfusion or by cardiac denervation. We investigate the efficacy of TMR and thoracic sympathectomy (TS) for relief of angina and whether any clinical benefit is associated with enhanced myocardial perfusion.
Twenty consecutive patients with nonrevascularizable coronary arteries and intractable angina were prospectively randomized to have TMR by holmium: yttrium aluminum garnet laser or TS. Subjects were clinically evaluated before, and for 42 months after, surgery. They underwent exercise tolerance testing and rest and stress quantitative perfusion magnetic resonance imaging (MRI) before, and 6 months after surgery.
The demographics of the two groups were similar. There was no perioperative mortality; however, two patients died in the TS group during follow-up. The Canadian Cardiovascular Society angina score improved from 3.4 +/- 0.5 to 2.6 +/- 1.1 (p = 0.06) in the TS group at 6 months but returned to 3.2 +/- 0.7 at 42 months, while in the TMR group it improved from 3.6 +/- 0.5 to 1.9 +/- 0.7 (p = 0.008) at 6 months and deteriorated to 2.5 +/- 0.9 (p = 0.01) after 42 months of surgery. The TMR-treated patients showed significant improvements in the SF-36 scores and Seattle Angina Questionnaire only at 6 months, whereas TS-treated patients did not show amelioration at any time during follow-up. The MRI protocol was completed in 15 of 20 (TMR = 8; TS = 7) patients and no significant differences in qualitative or quantitative perfusion variables were demonstrated in either group.
A greater clinical benefit was obtained with TMR than with TS early after surgery but this clinical effect did not seem to be associated with improvement in myocardial perfusion as assessed by MRI and part of the beneficial effect was lost by 42 months after surgery.
经心肌激光血运重建术（TMR）是缓解顽固性心绞痛的一种有效治疗方法。这种益处可能是通过增加心肌灌注或通过心脏去神经支配介导的。我们研究了TMR和胸交感神经切除术（TS）缓解心绞痛的疗效，以及是否有任何临床益处与增强心肌灌注相关。
连续20例冠状动脉不可再血管化且心绞痛难以控制的患者被前瞻性随机分为钬：钇铝石榴石激光TMR组或TS组。在手术前以及手术后42个月对受试者进行临床评估。他们在手术前和手术后6个月接受运动耐量测试以及静息和负荷定量灌注磁共振成像（MRI）检查。
两组的人口统计学特征相似。围手术期无死亡病例；然而，TS组有2例患者在随访期间死亡。TS组在6个月时加拿大心血管学会心绞痛评分从3.4±0.5改善至2.6±1.1（p = 0.06），但在42个月时恢复至3.2±0.7，而TMR组在6个月时从3.6±0.5改善至1.9±0.7（p = 0.008），在手术后42个月恶化至2.5±0.9（p = 0.01）。仅在6个月时，接受TMR治疗的患者在SF - 36评分和西雅图心绞痛问卷方面有显著改善，而接受TS治疗的患者在随访期间任何时候均未显示改善。20例患者中有15例（TMR = 8；TS = 7）完成了MRI检查，两组在定性或定量灌注变量方面均未显示出显著差异。
与TS相比，TMR在手术后早期获得了更大的临床益处，但这种临床效果似乎与MRI评估的心肌灌注改善无关，并且部分有益效果在手术后42个月时丧失。
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