Transmyocardial laser revascularization in ischemic cardiomyopathy

Background: In ischemic cardiomyopathy (left ventricular ejection fraction [LVEF] less than or equal to 30%), myocardial revascularization by coronary artery surgery has better results than heart transplantation, provided the re is sufficient ischemic but viable myocardium. The mode of action of tran smyocardial laser revascularization (TMR) is still being debated, but if th e procedure induces improved myocardial perfusion it could be a "bridge," o r alternative, to heart transplantation. Methods: We retrospectively analyzed 194 patients, who underwent TMR betwee n July 1997 and October 1999. Patients with TMR as an adjunct to coronary a rtery surgery (n = 30) and those who did not provide written consent to the procedure (n = 8) were excluded; 126 patients had normal or moderately red uced left ventricular function, and 30 patients with ischemic cardiomyopath y (LVEF less than or equal to 30%) were included. Results: After 12 months, the Canadian Cardiovascular Society (CCS) score d ropped significantly from 3.6 (3 to 4) to 2.4 (1 to 4) and maximum work loa d increased significantly from 58 W (25 to 100 W) to 73 W (25 to 120 W). Ho wever, thallium score and LVEF did not improve significantly (27% [15% to 3 0%] to 32% [15% to 45%]). Prior to the TMR procedure, all 30 patients had a "low risk" or "medium risk" of death according to the Aaronson classificat ion. The 30-day, 1-year, and 2-year survival rates were 83%, 50%, and 47%, respectively. Conclusions: We conclude that TMR in ischemic cardiomyopathy (LVEF less tha n or equal to 30%) has a perioperative risk comparable to that for heart tr ansplantation, but there is no improvement of myocardial performance or lif e expectancy. Therefore, TMR cannot be regarded as a "bridge," or alternati ve, to transplantation. However, in individual cases with contraindications for transplantation the anti-anginal effect may justify use of the procedu re.