Transmyocardial laser revascularisation in Edinburgh.

UNLABELLED

This paper describes a feasibility study to evaluate the Xenon-Chloride Excimer laser in patients requiring myocardial revascularisation.

METHODS

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.

RESULTS

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.

CONCLUSION

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.