Transmyocardial revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease

Background The construction of subendocardial channels to perfuse ischemic areas of the myocardium has been investigated since the 1950s. We assessed the safety and efficacy of transmyocardial revascularization with a carbon dioxide laser in patients with refractory angina and left ventricular free- wall ischemia that was not amenable to direct coronary revascularization. Methods In a prospective, controlled, multicenter trial, we randomly assign ed 91 patients to undergo transmyocardial revascularization and 101 patient s to receive continued medical treatment. The severity of angina (according to the Canadian Cardiovascular Society [CCS] classification), quality of l ife, and cardiac perfusion (as assessed by thallium-201 scanning) were eval uated at base line and 3, 6, and 12 months after randomization. Results At 12 months, angina had improved by at least two CCS classes in 72 percent of the patients assigned to transmyocardial revascularization, as compared with 13 percent of the patients assigned to medical treatment who continued medical treatment (P<0.001). Patients in the transmyocardial-reva scularization group also had a significantly improved quality of life as co mpared with the medical-treatment group. Myocardial perfusion improved by 2 0 percent in the transmyocardial-revascularization group and worsened by 27 percent in the medical-treatment group (P = 0.002). In the first year of f ollow-up, 2 percent of patients assigned to undergo transmyocardial revascu larization were hospitalized because of unstable angina, as compared with 6 9 percent of patients assigned to medical treatment (P<0.001). The perioper ative mortality rate associated with transmyocardial revascularization was 3 percent. The rate of survival at 12 months was 85 percent in the transmyo cardial-revascularization group and 79 percent in the medical-treatment gro up (P = 0.50). Conclusions In patients with angina refractory to medical treatment and cor onary artery disease that precluded coronary-artery bypass surgery or percu taneous transluminal coronary angioplasty, transmyocardial revascularizatio n improved cardiac perfusion and clinical status over a 12-month period. (N Engl J Med 1999;341:1021-8.) (C)1999, Massachusetts Medical Society.