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Published on: May 28, 2019
Procedural results and early clinical outcome of percutaneous transluminal myocardial revascularization
F A Shawl1, M J Domanski, U Kaul
1The Department of Interventional Cardiology, Washington Adventist Hospital, Takoma Park, Maryland 20912, USA.
Insights
Percutaneous transluminal myocardial revascularization (PTMR) offers a safe, nonoperative approach for refractory angina patients unsuitable for traditional revascularization. This laser-guided procedure creates channels, significantly improving symptoms with low complication rates.
Area of Science:
- Cardiology
- Minimally Invasive Procedures
- Interventional Cardiology
Background:
- Medically refractory angina affects patients not eligible for angioplasty or bypass surgery.
- Surgical myocardial revascularization offers symptom relief but carries high perioperative mortality.
- A need exists for safer, less invasive angina treatment options.
Purpose of the Study:
- To evaluate the safety and efficacy of a percutaneous transluminal myocardial revascularization (PTMR) technique.
- To assess symptom relief and procedural complications in patients with refractory angina.
Main Methods:
- Twenty-seven patients with unsuitable coronary anatomy underwent PTMR using a Holmium:YAG laser.
- Channels were created in the ventricular myocardium via a percutaneous catheter-based approach.
- Safety endpoints included mortality, tamponade, and creatine phosphokinase levels.
Main Results:
- No procedure-related deaths or tamponade occurred; one patient had elevated creatine phosphokinase.
- All patients were discharged alive with a mean hospital stay of 1.8 days.
- Canadian Cardiovascular Society functional class significantly improved from 3.6 to 0.65 at 30 days (p < 0.01).
- At 6 months, 9 of 12 patients showed no ischemic evidence on stress testing.
Conclusions:
- PTMR is a safe, nonoperative procedure for refractory angina in the cardiac catheterization lab.
- The complication rate is lower than surgical series, with excellent near-term symptom relief.
- Long-term outcomes, mortality benefits, and comparisons to surgical approaches require further definition.
Abstract:
A substantial number of patients present with medically refractory angina who are not candidates for angioplasty or bypass surgery. The creation of channels between the myocardium and the ventricular blood pool has been performed after thoracotomy with excellent relief of symptoms but has been associated with high perioperative mortality. We investigated the safety of a nonoperative, percutaneous technique for channel creation. Twenty-seven patients with angina and coronary anatomy not amenable to revascularization with coronary angioplasty or bypass surgery underwent percutaneous transluminal myocardial revascularization (PTMR). Energy from a Holmium:yttrium-aluminum-garnet (YAG) laser was directed through a fiber enclosed in a catheter to the ventricular myocardium creating channels between the blood pool and the myocardium. On average, 17 +/- 4 channels were formed per patient. There were no procedure-related deaths, episodes of tamponade, or other complications except for an increase in creatine phosphokinase in 1 patient. Immediately after the procedure, there was no worsening of regional wall motion function in any patient, but rather improvement in some. All patients were discharged alive after a hospital stay of 1.8 +/- 1.5 days. Mean Canadian Cardiovascular Society functional class declined from 3.6 +/- 0.5 before the procedure to 0.65 +/- 0.8 at 30 days after the procedure (p < 0.01). For 12 patients eligible for 6-month follow-up, mean functional class was 0.94 +/- 0.97. At 6-month stress testing, 9 of these 12 had no electrocardiographic evidence of ischemia. Thus, PTMR can be performed safely in the cardiac catheterization laboratory with a complication rate lower than that reported in surgical series and with excellent near-term symptomatic relief. The long-term effect of PTMR on mortality and relief of angina as well as its safety and effectiveness compared with the surgical approach remains to be defined.
