Results of transmyocardial laser revascularization in non-revascularizable coronary artery disease after 3 years follow-up [ssee comments].

BACKGROUND

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.

METHODS AND RESULTS

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).

CONCLUSION

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%.