END-STAGE CORONARY-DISEASE TREATED WITH THE TRANSMYOCARDIAL CO2-LASERREVASCULARIZATION - A CHANCE FOR THE INOPERABLE PATIENT

Objective: The aim of this study is to evaluate the short and mid-term efficacy of the Transmyocardial High Power CO, Laser Revascularisatio n (TMLR) as a last resource method for end-stage coronary disease pati ents. Method and patients: The High Power CO2 Laser 800 W Heart Laser (PLC Medical Systems) was used since February 1994 to treat 268 patien ts. In 52% of the cases (140) the indication for TMLR treatment was vi rtual inoperability by the classical bypass revascularisation. In the other 128 patients (48%), where only an incomplete revascularisation w as expected, the TMLR was combined with a feasible bypass revascularis ation (CABG). Of all patients, 71% were operated on 1-5 times before a nd or treated by several percutaneous transluminal coronary angioplast y (PTCA). All patients were sufferers of angina pectoris and most were classified Canadian Cardiac Society (CCS) 3-4, despite the maximal me dical treatment. The ejection fraction was normal in 13% of patients o nly, and in 47% of them it was below 40% (10-68%). Results: The operat ion itself was generally well tolerated. We lost only one patient at t he table. The hospital survival was 89.2%; 88.2% in the combined group and 90.3% in the TMLR only group. After the routine follow up screeni ng 3, 6 and 12 months postoperatively (262 patients-131 TMLR and 131 T MRL/CABG), 40% of the TMLR patients upgraded into the functional class CCS 0-1; the combined group of patients scored up even in 84%. All co nsidering their quality of life to be 'better than years ago'. The erg ometry stress test, impossible for most of them before, became feasibl e and better in 80% of the patients. In the follow up period of the co mbined group, another 6 (4.7%), and in the TMLR only group, 12 (9.4%) patients died. Conclusion: The short and middle term results of this-u ntil now the largest single institution series of TMLR treated patient s-were that patients almost without exception were refused for any kin d of surgery by several other centres; this shows an acceptable surviv al rate and a surprising level of pain relief, increased activity and better quality of life then ever expected. In our experience, TMLR is a suitable method for treatment of end stage coronary disease, if all standard measures, medical therapy, PTCA and redo coronary revasculari sation possibilities are exhausted. The favourable results imply the q uestion as to whether this method will become an alternative for a sec ond bypass operation in the future. The TMLR as an alternative for hea rt transplant is already a reality for some of our patients. (C) 1997 Elsevier Science B.V.