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Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded,
K B Allen1, R D Dowling, A J DelRossi
1Departments of Cardiothoracic Surgery, St Vincent Hospital, Indiana Heart Institute, Indianapolis, IN, USA. cvsurgeon@iquest.com
Insights
Transmyocardial revascularization combined with coronary artery bypass grafting (CABG) showed improved operative and 1-year survival in patients not suitable for complete bypass alone. Angina relief was similar between groups at 12 months.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Regenerative Medicine
Background:
- Coronary artery disease (CAD) remains a leading cause of mortality worldwide.
- Complete revascularization is crucial for optimal outcomes in CAD patients.
- Transmyocardial revascularization (TMR) offers a potential solution for non-graftable ischemic areas.
Purpose of the Study:
- To evaluate the safety and efficacy of TMR combined with CABG.
- To compare outcomes in patients not amenable to complete revascularization by CABG alone.
- To assess operative mortality, survival rates, and clinical endpoints.
Main Methods:
- A prospective, randomized, multicenter trial involving 263 patients.
- Patients were randomized to either CABG + TMR (n=132) or CABG alone (n=131).
- Primary endpoints included operative mortality and 1-year survival; secondary endpoints included adverse cardiac events and angina relief.
Main Results:
- The CABG + TMR group had significantly lower operative mortality (1.5% vs. 7.6%, P=.02).
- One-year survival favored the CABG + TMR group (95% vs. 89%, P=.05).
- Both groups showed similar improvements in angina and exercise treadmill scores at 12 months.
Conclusions:
- Adjunctive TMR to CABG is safe and associated with improved operative and 1-year survival in selected patients.
- Angina relief and functional improvement were comparable between groups at 12 months.
- Larger validation studies are needed to confirm these survival benefits.
Objective:
We sought to assess the safety and efficacy of transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone.
Methods:
A total of 263 patients whose standard of care was coronary artery bypass grafting and who had one or more ischemic areas not amenable to bypass grafting were prospectively randomized to receive coronary bypass of suitable vessels plus transmyocardial revascularization to areas not graftable (n = 132) or coronary bypass alone with nongraftable areas left unrevascularized (n = 131). Group preoperative demographics and operative characteristics were similar.
Results:
The operative mortality rate after coronary bypass/transmyocardial revascularization was 1.5% (2/132) versus 7.6% (10/131) after coronary bypass alone (P =.02). Patients undergoing both coronary bypass and transmyocardial revascularization required less postoperative inotropic support (30% vs 55%, P =.0001) and had a trend toward fewer insertions of intra-aortic balloon pumps (4% vs 8%, P =.13) than did patients having coronary bypass alone. Multivariable predictors of operative mortality were coronary artery bypass alone (odds ratio, 5.3; 95% confidence interval, 1.1-25.7; P =.04) and increased age (odds ratio, 1.1; 95% confidence interval, 1. 0-1.2; P =.03). One-year Kaplan-Meier survival (95% vs 89%, P =.05) and freedom from major adverse cardiac events defined as death or myocardial infarction (92% vs 86%, P =.09) favored the combination of coronary bypass and transmyocardial revascularization. Baseline to 12-month improvement in angina and exercise treadmill scores was similar between groups.
Conclusions:
In a prospective, randomized, multicenter trial, transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone was safe; however, angina relief and exercise treadmill improvement were indistinguishable between groups at 12 months of follow-up. Operative and 1-year survival benefits observed after adjunctive transmyocardial revascularization require confirmation by a larger validation study, which is ongoing.