Influence of the availability of laser transmyocardial revascularisation on surgical strategy in patients with advanced coronary artery disease

Objective: To compare the planned and actual revascularisation techniques u sed in patients undergoing cardiac surgery for refractory angina when excim er transmyocardial laser revascularisation (TMR) is available. Methods: Obs ervational series of 31 patients (mean age 65 years) with severe angina [me an CCS score (SD) 3.8 (0.4)] and three-vessel coronary artery disease judge d unsuitable for conventional bypass surgery alone. All patients underwent cardiac surgery: revascularisation techniques were determined by the operat ive findings. Results: Pre-operative strategy was altered by the intraopera tive findings in 13 patients (42%). In 5 (16%), the coronary vessels proved graftable and TMR was unnecessary. Conversely, in 6 patients (19%) an anti cipated graft could not be performed and TMR was used as an alternative. In 2 patients (7%), neither strategy was possible. Overall, TMR was performed as a stand-alone procedure in 9 (29%) and combined with CABG in 17 (55%). Operative mortality was low: 0% at 30 days and 6% at 6 months. Mean CCS cla ss (SD) improved post-operatively from 3.8 (0.4) to 1.7 (1.1) (p < 0.01). C onclusions: The preoperative coronary angiogram is an imperfect predictor o f which coronary vessels are suitable for grafting. The availability of las er TMR allows the cardiac surgeon to accept cases which would otherwise be considered inoperable and to respond better to intraoperative findings. The combination of laser TMR and bypass grafts provides good short- and medium -term symptomatic improvement with a low post-operative mortality. Copyrigh t (C) 2001 S. Karger AG. Basel.