TRANSMYOCARDIAL LASER REVASCULARIZATION - TREATMENT OPTION FOR CORONARY-ARTERY DISEASE

Transmyocardial laser revascularization (TMR) is a new therapeutic pri nciple for patients with coronary artery disease and no possibility of conventional revascularization with CABG or PTCA. The clinical value of the method is not known. Therefore we investigated all 46 patients treated with sole TMR in our center using clinical investigation, LV a nd coronary angiography, right heart catheterization, MLBI perfusion i maging and myocardial FDG-PET pre- and 6 months post TMR. 117 patients judged not suitable for conventional revascularization procedures wer e submitted for TMR. The indication for the procedure was reevaluated in every case. 52 patients (mean EF 41 +/- 16 %) could be further trea ted by intensified anti-anginal medication, seven patients received by pass grafts, four patients had PTCA, three patients were Listed for he art transplantation, and five patients had a combined CABG plus TMR. O nly 46 (38 % of the submitted patients, mean EF 55 +/- 15 %) were acce pted for sole TMR. CCS class of these patients was 3.3 +/- 0.4, mean a ge was 63.6 +/- 7.3 years, 70 % were males. The postoperative mortalit y within 30 days was 5/46 (10.8 %); 9/46 patients (19.5 %) suffered fr om perioperative myocardial infarction. Other complications were ventr icular fibrillation in two cases on the second postoperative day and a rupture of the spleen on the 14th postoperative day. 8/46 patients (1 7 %) had wound infections. Survivors showed an improvement in their CC S class (1.9, 2.1, 1.9 after 3, 6 and 12 months, respectively, mean ob servation time 0.61 +/- 0.4 years). These patients were able to perfor m bicycle stress tests significantly longer (98 s +/- 9 pre versus 120 +/- 13 s post TMR, p = 0.01). Angiographic EF fell from 57.8 % +/- 15 % to 52.6 % +/- 19 % (p = 0.02) and the number of hypokinetic chords rose from 23.6 +/- 20.9 % to 30.6 +/- 24.1% per patient (p = 0.008), p redominantly in the inferior wall. Nuclear studies showed reduced myoc ardial perfusion and vitality after TMR. Four patients in the TMR grou p had reintervention (PTCA) because of progression of coronary scleros is of native vessels. One patient had mitral valve replacement due to severe regurgitation. Kaplan-Meier analysis showed no significant diff erence in survival between the TMR and the medical group when stratifi ed according to initial ejection fraction. Sudden death and congestive heart failure are the most important causes of mortality. Our data sh ow that TMR improves symptoms and exercise performance of otherwise no t treatable patients with diffuse coronary artery disease. Due to a la ck of an improvement of cardiac perfusion, function or prognosis TMR s hould be used only in highly selected cases when conventional methods fail to improve patients symptoms.