TRANSMYOCARDIAL REVASCULARIZATION IN PATIENTS WITH REFRACTORY, UNSTABLE ANGINA

Background-Previous reports of transmyocardial revascularization (TMR) indicate a significant mortality in patients with refractory, unstabl e angina. We hypothesized that TMR with a holmium laser would result i n significant angina relief with acceptable mortality in this patient population. Methods and Results-Patients were defined as unstable if t hey were unweanable from intravenous antianginal medications or were t oo unstable for a persantine thallium scan. Patients had a left ventri cular ejection fraction (LVEF) of >25% and were not amenable to CABG o r PTCA. Before treatment, all patients had class TV angina. TMR was pe rformed in 85 patients, with a mean of 35+/-11 transmural laser channe ls. Mean age was 63+/-10 years. Mean LVEF was 48+/-11%. Of these patie nts, 79% were men. Prior CABG and/or PTCA had been performed in 87% of patients, and 72% of patients had a history of prior MI. Operative mo rtality was 12% (10 of 85), There were 2 deaths between discharge and 3 months after surgery and 7 late deaths from 6 to 12 months after sur gery. Twelve-month mortality was 22.4% (19 of 85). At 3 months, 86% of patients had class II angina or better. At 6 and 12 months, 77% and 7 5% of patients, respectively, had class LI angina or better. Mean angi na class at 6 and 12 months' follow-up was 1.5+/-1.1 and 1.6+/-1.3, re spectively. Conclusions-In patients with refractory unstable angina, T MR with a holmium laser provided significant angina relief. Moreover, 30-day operative mortality and 12-month mortality were acceptable, esp ecially given this subset of unstable patients with refractory angina.