Technique of transmyocardial revascularization: avoiding complications in high-risk patients

Background, Transmyocardial revascularization (TMR) is an emerging therapy for coronary artery disease, with 7 years of published clinical research an d nearly three years of clinical application. Every report thus far has con firmed that TMR relieves severe angina pectoris. It is primarily an alterna tive therapy for angina which has been refractory to conventional medical a nd surgical treatment. Operative mortality of 3% to 10% has been reported. Methods. Seventy-seven patients were treated with TMR using a Holmium: YAG laser. Admission criteria included severe angina despite high doses of at l east two anti-angina medications and nitroglycerin, reversible ischemia by thallium scan, and unsuitability for CABG or angioplasty. Patients had end- stage ischemic heart disease and multiple previous conventional procedures. TMR was performed through small left anterior thoracotomies using a 10.16 cm or less incision. Results. Seventy-five patients recovered from surgery without major complic ations. One patient (1.3%) died of an autopsy-proven myocardial infarction in the treated region, and two additional patients had a myocardial infarct ion (4.3%). Four patients had paresis of the left phrenic nerve, as determi ned by an elevated left hemidiaphragm on chest X-ray, from which three reco vered fully. Patients had no bleeding or wound infections. Patients were in tubated for an average of 1.5 hours and remained in ICU an average 0.8 days . Mean hospitalization was 3.4 days. Conclusions. Technically well-done TMR through a small anterior thoracotomy can have good therapeutic results and low morbidity and mortality. We will describe operative techniques which minimize pain and stress and help to i nsure surgical success.