Nägele H, Stubbe H M, Nienaber C, Rödiger W
Department of Cardiac Surgery, University Hospital Eppendorf, Hamburg, Germany.
Eur Heart J. 1998 Oct;19(10):1525-30. doi: 10.1053/euhj.1998.1152.
Transmyocardial laser revascularization is a new therapeutic option for end-stage coronary artery disease if no other cardiological or cardiosurgical intervention is possible. Data are few on how patients fare after more than 1 year follow-up.
From a total of 157 patients who were suggested for transmyocardial laser therapy in the years 1995-1997, 126 were judged to have non-revascularizable coronary artery disease (mean age 61.9 +/- 14 years, 80% men, mean left ventricular ejection fraction 46.2 +/- 17.1%). Sixty-six patients had a good clinical response to intensification of the antianginal therapy and were therefore treated further medically. In 60 patients with refractory angina, sole transmyocardial laser revascularization without cardiopulmonary bypass or additional grafts was performed. The transmyocardial laser revascularization group was 32% female; 78.3% patients had had bypass operations; the mean left ventricular ejection fraction was 53.6 +/- 15%. Eighty five percent of the transmyocardial laser revascularization patients had demonstrable ischaemic regions, as visualized by dipyridamol-MIBI scintigraphy. The percentage of patients with some hibernating myocardium in positron emission tomography studies was 70%. Good early relief of angina symptoms was experienced by patients who had undergone laser treatment. After 3 months the Canadian Cardiovascular Society class fell from 3.31 +/- 0.51 to 1.84 +/- 0.77 in 49 patients (P < 0.0001), but increased in the total group to 2.02 +/- 0.92 after 6 months (n = 47), to 2.26 +/- 0.99 after 1 year (n = 42), to 2.47 +/- 1.11 after 2 years (n = 38) and to 2.58 +/- 0.9 after 3 years (n = 19). MIBI/positron emission tomography data at rest and after 6 months was worse in patients in whom pre- and postoperative studies were complete (n = 22). The peri-operative mortality was 12% (n = 7: peri-operative myocardial infarction, low output syndrome, arrhythmia). Mortality after 1 and 3 years was 23% and 30%, respectively. The risk of transmyocardial laser revascularization was significantly elevated in patients with left ventricular ejection fraction < 40%. Late deaths (n = 9) were due to sudden arrhythmias or pump failure. There was a high rate of cardiac events and reinterventions in the transmyocardial laser revascularization group, including percutaneous transluminal coronary angioplasty in newly developed lesions (n = 7), valve replacement (n = 2), need for intermittent urokinase therapy (n = 5) and heart transplantation (n = 2).
Fifty percent of patients with non-revascularizable coronary artery disease submitted for transmyocardial laser revascularization can be stabilized medically. Transmyocardial laser revascularization led to a rapid early relief of symptoms, but with a trend towards worsening over time and showed a high peri-operative risk (> 10%) dependent on the pre-operative ejection fraction. Our data were in contrast to other published reports on the more beneficial effects of transmyocardial laser revascularization and should lead to further investigation of this experimental method. Transmyocardial laser revascularization should only be performed after failure of maximal anti-anginal therapy, and should be avoided when the left ventricular ejection fraction is < 40%.
对于终末期冠状动脉疾病患者，若无法进行其他心脏科或心脏外科干预，经心肌激光血运重建术是一种新的治疗选择。关于患者随访1年以上的情况，相关数据较少。
1995年至1997年期间，共有157例患者被建议接受经心肌激光治疗，其中126例被判定为冠状动脉疾病无法进行血运重建（平均年龄61.9±14岁，80%为男性，平均左心室射血分数46.2±17.1%）。66例患者对抗心绞痛治疗强化有良好临床反应，因此继续接受药物治疗。60例难治性心绞痛患者仅接受了无体外循环或额外移植的经心肌激光血运重建术。经心肌激光血运重建术组中女性占32%；78.3%的患者曾接受过搭桥手术；平均左心室射血分数为53.6±15%。85%的经心肌激光血运重建术患者有可证实的缺血区域，通过双嘧达莫 - MIBI心肌灌注显像可见。正电子发射断层扫描研究中，有冬眠心肌的患者比例为70%。接受激光治疗的患者早期心绞痛症状得到明显缓解。3个月后，49例患者的加拿大心血管学会分级从3.31±0.51降至1.84±0.77（P<0.0001），但6个月后全组升至2.02±0.92（n = 47），1年后升至2.26±0.99（n = 42），2年后升至2.47±1.11（n = 38），3年后升至2.58±0.9（n = 19）。术前和术后研究完整的患者（n = 22）静息及6个月后的MIBI/正电子发射断层扫描数据较差。围手术期死亡率为12%（n = 7：围手术期心肌梗死、低心排血量综合征、心律失常）。1年和3年后的死亡率分别为23%和30%。左心室射血分数<40%的患者经心肌激光血运重建术风险显著升高。晚期死亡（n = 9）原因是突发性心律失常或泵衰竭。经心肌激光血运重建术组心脏事件和再次干预发生率较高，包括新发病变的经皮冠状动脉腔内血管成形术（n = 7）、瓣膜置换术（n = 2）、间歇性尿激酶治疗需求（n = 5）和心脏移植（n = 2）。
接受经心肌激光血运重建术的冠状动脉疾病无法进行血运重建患者中，50%可通过药物治疗稳定病情。经心肌激光血运重建术可使症状快速早期缓解，但随时间有恶化趋势，且围手术期风险较高（>10%），取决于术前射血分数。我们的数据与其他关于经心肌激光血运重建术更有益效果的已发表报告相反，应促使对这种实验方法进行进一步研究。经心肌激光血运重建术应仅在最大抗心绞痛治疗失败后进行，且当左心室射血分数<40%时应避免使用。
