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Early experience with transmyocardial laser revascularization
F Memon1, M Moinuddin, S Qureshi
1King Fahad Heart Center, King Fahad Hospital, Jeddah.
Insights
Transmyocardial Laser Revascularization (TMR) offers a viable alternative for patients with severe coronary artery disease unsuitable for traditional bypass surgery. This study shows TMR improves heart function, exercise capacity, and reduces angina symptoms.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Medical Technology
Background:
- Coronary artery disease (CAD) treatment options include Coronary Artery Bypass Grafting (CABG), medical therapy, and percutaneous transluminal coronary angioplasty (PTCA).
- A subset of CAD patients with diffuse or small vessel disease are not candidates for conventional grafting procedures.
- Transmyocardial Laser Revascularization (TMR) presents a novel surgical approach for these challenging cases.
Purpose of the Study:
- To evaluate the efficacy and safety of Transmyocardial Laser Revascularization (TMR) in patients with non-graftable coronary artery disease.
- To assess the impact of TMR on left ventricular ejection fraction (LVEF), exercise tolerance, and angina symptoms.
Main Methods:
- A cohort of 100 patients with non-graftable CAD underwent TMR at King Fahad Heart Center between February 1994 and February 1996.
- Patients were followed for 12 months with assessments including LVEF, exercise testing (VO2 max), clinical evaluation, and myocardial perfusion scans.
- Surgical mortality and the need for anti-anginal medications were recorded.
Main Results:
- TMR demonstrated a statistically significant increase in LVEF and exercise time (VO2 max) at 6 and 12 months post-procedure.
- Patients experienced significant clinical, hemodynamic, and symptomatic improvement, with a marked reduction in anti-anginal drug usage.
- Myocardial perfusion scan scores improved, indicating enhanced myocardial viability, while surgical mortality was 10% in this high-risk group.
Conclusions:
- Transmyocardial Laser Revascularization (TMR) is a reasonable alternative to medical management for patients with refractory angina due to diffuse, small vessel CAD, or occluded grafts unsuitable for CABG.
- TMR offers significant functional and symptomatic benefits in carefully selected high-risk patient populations.
Abstract:
Conventional treatment of coronary artery disease consists of either Coronary Artery Bypass Grafting (CABG), medical therapy or percutaneous transluminal coronary angioplasty (PTCA) or a combination. However, certain group of patients do not even qualify for CABG. Transmyocardial Laser Revascularization (TMR) is a unique new surgical modality specially for that sub group of patient population who have small and diffuse coronary artery disease not suitable for grafting. King Fahad Heart Center initiated its TMR program in February, 1994 and until February, 1996, 100 patients under went the TMR procedure. Eighty-one were males and 19 females with a mean average age of 55 years. Seventy-nine patients had 3 vessel disease (VD) and 66 patients had non-graftable small vessels. Ten patients had left ventricular ejection fraction (LVEF) less than 30%. All the patients underwent a strict protocol of follow-up. The pre and post TMR assessment at six months and 12 months follow-up showed an increase in LVEF at six and 12 months as compared to pre TMR level. The exercise time also increased from a base line level at six months and showed further improvement at 12 months which was statistically significant (p < 0.05) along-with VO2 max, which also showed improvement. Clinically, haemodynamically and symptomatically these patients showed significant improvement and use of anti-anginal drugs (87%) was reduced to minimum. Isotope myocardial perfusion scan on 15 segment viability score showed an improvement from pre TMR level of 33.8 to 45.9 at post TMR 12 months follow up. The surgical mortality in this high risk TMR population was 10%. TMR was found to be a reasonable alternative to medical treatment in patients with angina due to diffuse and or small vessel disease or occluded previous grafts not amenable to CABG.
