Morgan I, Campanella C
Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh NHS Trust, UK.
Br J Theatre Nurs. 1998 Mar;7(12):4-9.
This paper describes a feasibility study to evaluate the Xenon-Chloride Excimer laser in patients requiring myocardial revascularisation.
Between November 1995 and September 1997, 30 patients (aged 48 to 80 years) underwent Transmyocardial Laser Revascularisation (TMR), either combined with coronary artery bypass grafting (CABG) or as a sole procedure. These patients were considered unsuitable for conventional coronary revascularisation on the basis of angiographic findings. Evaluation included NYHA status, exercise tolerance test, dobutamine stress echocardiography, Thallium myocardial perfusion scan, with follow-up scan at 3 months and clinical review at 3, 6, 12 and 18 months. Operative technique initially was standardised comprising median sternotomy, full cardiopulmonary bypass, moderate systemic hypothermia and induced ventricular fibrillation. This was later modified to mini-left anterior thoracotomy, femoral cannulation with venous centrifugal assist.
Patients undergoing TMR also had conventional grafts whenever possible (18/30 (60%), 1 graft 12/30, 2 grafts 6/30). 14 patients were redo cases, and 12 were unsuitable for further grafts, and therefore had TMR as a sole procedure. The number of channels created was between 6 and 100 (mean 45.6 +/- 20.7). The majority of the cases had severe angina (NYHA classes III or IV) at presentation, with an improvement of at least 2 points postoperatively (p < 0.001) which was sustained throughout the period of follow-up. Objective evidence of improved myocardial perfusion and function (dobutamine stress echocardiography and Thallium myocardial perfusion scan) was obtained in a few patients. Complications following TMR were uncommon-one patient developed complete AV dissociation requiring permanent pacemaker insertion. No other specific TMR-related complications were identified.
Despite initial difficulties in recruiting adequate numbers of patients, TMR has proved to be a useful adjunct in relieving angina in patients who are either poor candidates for surgery or unsuitable for full revascularisation. Modification in the technique has allowed a less invasive approach and improved recovery period.
本文描述了一项可行性研究，以评估氯化氙准分子激光在需要心肌血运重建的患者中的应用。
在1995年11月至1997年9月期间，30例年龄在48至80岁之间的患者接受了经心肌激光血运重建术（TMR），该手术要么与冠状动脉旁路移植术（CABG）联合进行，要么作为单独的手术。根据血管造影结果，这些患者被认为不适合进行传统的冠状动脉血运重建。评估包括纽约心脏协会（NYHA）心功能分级、运动耐量测试、多巴酚丁胺负荷超声心动图、铊心肌灌注扫描，并在术后3个月进行随访扫描，在3、6、12和18个月进行临床复查。手术技术最初标准化为正中胸骨切开术、全心肺转流、中度全身低温和诱发心室颤动。后来改为小切口左前开胸术、股静脉插管并使用静脉离心辅助装置。
接受TMR的患者尽可能同时进行了传统的移植手术（18/30（60%），1根移植血管12/30，2根移植血管6/30）。14例患者为再次手术病例，12例患者不适合进一步进行移植手术，因此将TMR作为单独的手术。创建的通道数量在6至100个之间（平均45.6±20.7）。大多数病例在就诊时患有严重心绞痛（NYHA III或IV级），术后至少改善2分（p<0.001），并且在整个随访期间持续改善。少数患者获得了心肌灌注和功能改善的客观证据（多巴酚丁胺负荷超声心动图和铊心肌灌注扫描）。TMR术后并发症不常见——1例患者发生完全性房室传导阻滞，需要植入永久性起搏器。未发现其他与TMR相关的特定并发症。
尽管最初在招募足够数量的患者方面存在困难，但TMR已被证明是缓解心绞痛的一种有用辅助手段，适用于手术效果不佳或不适合进行完全血运重建的患者。技术改进使得手术创伤更小，恢复期更短。
