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Transmyocardial laser revascularization: is the enthusiasm justified?
1Department of Medicine, Faculty of Medicine, Kuwait University, Safat.
Background:
Transmyocardial laser revascularization (TMLR) is advocated to offer relief of incapacitating angina for patients whose coronary vessels are poor targets for coronary artery bypass graft surgery (CABG) or balloon angioplasty and stenting. In spite of significant mortality and morbidity, the preliminary reports from centers performing the procedure were quite enthusiastic for a period of about 1 year following the procedure.
Hypothesis:
The study aimed to determine mortality, morbidity, and long-term results of TMLR.
Methods:
The study included 19 individuals with incapacitating angina not suitable for CABG or percutaneous balloon angioplasty. Patients were followed up clinically for death, myocardial infarction, heart failure, arrhythmia, and repeated hospital admissions for unstable angina or other conditions. Stress testing with radionuclide tracers was done following surgery in patients who were not unstable.
Results:
Of 19 patients, 8 experienced significant morbidity. There was one hospital death. Four died within 17 months. Relief from angina of two classes or more was present in 15 of 18 patients (83.3%) for a variable time period. Mean time for anginal relief was 8.0 months (range 1-30 months). At last follow-up, only two patients with a hybrid procedure (both CABG and TMLR in the same sitting) had mild angina for 17 and 29 months, respectively. All others with a mean follow-up period of 21.2 months (range 6-53 months) developed unstable angina or had a large area of ischemia on stress radionuclide studies. Despite a high incidence of significant angina in patients after TMLR, hospitalization was reduced from an average of 42.6 days pre procedure in the year before to 21 days during the follow-up period post procedure.
Conclusion:
Transmyocardial laser revascularization is associated with significant relief of angina pectoris in the majority of patients with severe diffuse coronary artery disease; however, this relief is short-lived in most. When mortality and morbidity are factored in, TMLR cannot be enthusiastically recommended.