PATIENTS PROFILES IN END-STAGE CORONARY-ARTERY DISEASE - INDICATIONS FOR TREATMENT WITH TRANSMYOCARDIAL LASER REVASCULARIZATION

There is a subgroup of patients with coronary artery disease who are r efractory to the therapeutical methods so far applied. We report on 12 8 patients who fulfill this definition and have therefore undergone pu re transmyocardial laser revascularisation (TMLR) or transmyocardial l aser revascularisation in combination with coronary bypass surgery at our institution. The patients can be characterized by a long history o f coronary artery disease with multiple revascularizing procedures, e. g. bypass surgery or percutaneous transluminal coronary angioplasty (P TCA), pronounced symptoms of coronary artery disease and chronic heart failure in the presence of markedly reduced left ventricular ejection fractions and intense antiischemic medical therapy. The patients were 62.2 +/- 9.8 (SD) years of age, in 89.9% of them at least one bypass operation and in 44.5% up to more than three percutaneous transluminal coronary angioplasties (PTCAs) had been performed prior to TMLR. Ther e was a history of myocardial infarction in 90.7% of patients and 89.8 % were in the Canadian Cardiovascular Society (CCS) classes III or IV and 94.5% of them were in the NYHA classes III or IV. The left ventric ular ejection fraction was 49.5 +/- 16.4% and all of the patients were under intense antiischemic medical treatment which included nitrates or molsidomine in 96.9%, beta blockers in 53.1%, angiotensin convertin g enzyme inhibitors (ACE inhibitiors) in 44.5%, digitalis in 22.7% and diuretics in 52.3% of patients. The preoperative data on myocardial v iability, inducible ischemia and coronary morphology provided importan t clinical information for the decision, which revascularizing method would be the most appropriate for each vessel or myocardial region. Th is had to be weighed against the patient's operative risk, which is pr edominantly determined by the left ventricular ejection fraction, the arteriosclerotic involvement of the remaining vascular system and conc omitant diseases, particularly of pulmonary origin.