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Survival after transmyocardial laser revascularization in relation to nonlasered perfused myocardial zones
E G Kraatz1, M Misfeld, B Jungbluth
1Clinic of Cardiac Surgery, Medical University of Lübeck, Germany.
Insights
Transmyocardial laser revascularization (TLR) improves angina but survival is uncertain. Patient survival after TLR is significantly influenced by the number of perfused myocardial zones via native vessels or grafts, not the procedure itself.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Medical Technology
Background:
- Transmyocardial laser revascularization (TLR) is used for severe coronary artery disease, but its impact on survival remains unclear.
- The longevity of TLR-created channels is limited, suggesting survival benefits may stem from other factors.
- This study investigates the role of myocardial perfusion in survival post-TLR.
Purpose of the Study:
- To evaluate the impact of myocardial perfusion zones on patient survival after transmyocardial laser revascularization (TLR).
- To determine if perfusion through native vessels or bypass grafts in non-TLR areas influences long-term outcomes.
Main Methods:
- A cohort of 63 patients underwent transmyocardial laser revascularization (TLR) between 1995 and 1997, with or without coronary artery bypass grafting (CABG).
- Patients were stratified into three groups based on the number of perfused myocardial zones (0, 1, or 2) via native arteries or grafts.
- Comprehensive follow-up was conducted over 36 months with 100% completion.
Main Results:
- Overall mortality was substantially higher in patients with zero perfused zones (77.8%) compared to those with one (20.8%) or two (13.3%) perfused zones.
- Hospital and late mortality rates, as well as cardiac deaths, were significantly elevated in the group with no perfused zones.
- The number of perfused myocardial zones demonstrated a statistically significant positive influence on patient survival (p=0.002).
Conclusions:
- Survival following transmyocardial laser revascularization (TLR) appears to be positively influenced by the extent of myocardial perfusion.
- Maintaining perfusion in non-TLR areas through native vessels or grafts is crucial for improving survival outcomes in these patients.
Background:
Transmyocardial laser revascularization for severe diffuse coronary artery disease reduces angina significantly. The effect on survival, however, is questionable, and risk factors are not adequately addressed. Considering that transmyocardial laser revascularization channels do not remain patent for improving direct myocardial blood supply, other variables such as perfusion through open native or grafted vessels in remote non-transmyocardial laser revascularization areas are probably more important for survival. This hypothesis is the subject of the study.
Methods:
Transmyocardial laser revascularization was performed with a CO2 laser system in 63 patients between October 1995 and December 1997. Patients received transmyocardial laser revascularization alone or in combination with coronary artery bypass grafting. The heart was divided into three perfusion zones as determined by the three major coronary arteries. Patients were divided into three groups according to the number of zones that were perfused by either a native coronary artery or a patent bypass graft: group 1 (n = 9), none; group 2 (n = 24), one; and group 3 (n = 30), two. Follow-up was performed at 3, 6, 12, 24, and 36 months and was 100% complete. Mean latest follow-up was 26.2 months, minimal follow-up of survivors was at least 12 months.
Results:
Overall mortality was remarkably higher in group 1 (77.8%) compared with group 2 (20.8%, p = 0.005) and group 3 (13.3%, p = 0.001). Hospital mortality was 22.2% in group 1, 0% in group 2, and 3.3% in group 3. Late mortality was also higher in group 1 (55.5% versus 20.8%, and versus 9.9%, respectively). Cardiac deaths were more frequent in group 1 (55.5% versus 12.5% in group 2, p = 0.02, and versus 9.9% in group 3, p = 0.009). The number of perfused myocardial zones showed a significant influence for survival (p = 0.002).
Conclusions:
These data give some directional evidence that survival seems to be beneficially affected by the number of nonlasered perfused myocardial zones through native vessels or grafts in patients undergoing transmyocardial laser revascularization.
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