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Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting: a randomized, multicenter
O H Frazier1, Egemen Tuzun, Harald Eichstadt
1Cardiopulmonary Transplant Service and the Cullen Cardiovascular Research Laboratories of the Texas Heart Institute, Houston, Texas 77030, USA.
Insights
Transmyocardial laser revascularization (TMLR) combined with coronary artery bypass grafting (CABG) showed improved success and reduced repeat revascularization in severe coronary artery disease patients. This combination therapy appears safe for high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Medical Technology
Background:
- Severe coronary artery disease (CAD) often involves regions unsuitable for traditional bypass grafting.
- Transmyocardial laser revascularization (TMLR) is an alternative or adjunct therapy for such cases.
- Evaluating the efficacy and safety of combining TMLR with coronary artery bypass grafting (CABG) is crucial.
Purpose of the Study:
- To compare the outcomes of TMLR combined with CABG versus CABG alone in patients with severe CAD.
- To assess the impact on angina relief, need for repeat revascularization, and overall survival.
- To evaluate the safety profile of the combined approach in high-risk patients.
Main Methods:
- A randomized trial at four centers involving 44 patients with severe CAD.
- Patients were assigned to either CABG plus TMLR (n=23) or CABG alone (n=21).
- Outcomes including mortality, morbidity, angina status, and repeat revascularization were monitored up to 4 years.
Main Results:
- The combined CABG+TMLR group showed no significant difference in short-term mortality (13% vs. 28%) or in-hospital adverse events.
- Both groups experienced significant angina relief and improved functional status at 1 and 4 years.
- The CABG+TMLR group demonstrated a significantly lower incidence of repeat revascularization (0% vs. 24%) and a trend towards improved 4-year event-free survival (39% vs. 14%).
Conclusions:
- Combining TMLR with CABG is safe for high-risk patients with severe CAD.
- The combination therapy may improve overall success rates and reduce the need for repeat revascularization.
- Enhanced perfusion of ischemic regions not amenable to bypass might explain the improved outcomes, warranting further investigation.
Abstract:
We evaluated transmyocardial laser revascularization (TMLR) with coronary artery bypass grafting (CABG) versus CABG alone for severe coronary artery disease involving 21 myocardial region unsuited for CABG. At 4 centers, 44 consecutive patients were randomized for CABG+TMLR (n = 23) or CABG alone (n = 21). Operative and in-hospital mortality and morbidity rates were monitored. Clinical status was evaluated at hospital discharge, 1 year, and 4 years. Success was characterized by relief of angina and freedom from repeat revascularization and death. Preoperatively, 20 patients (47%) were at high risk. The CABG technique, number of grafts, and target vessels were similar in both groups. Patients undergoing CABG+TMLR received 25 +/- 11 laser channels. Their < or = 30-day mortality was 13% (3/23) compared with 28% (6/21) after CABG alone (P = 0.21). There were no significant intergroup differences in the number of intraoperative or in-hospital adverse events. The follow-up period was 50.3 +/- 17.8 months for CABG alone and 48.1 +/- 16.8 months for CABG+TMLR. Both groups had substantially improved angina and functional status at 1 and 4 years, with no significant differences in cumulative 4-year mortality. The incidence of repeat revascularization was 24% after CABG alone versus none after CABG+TMLR (P < 0.05). The 4-year event-free survival rate was 14% versus 39%, respectively (P < 0.064). In conclusion, CABG+TMLR appears safe and poses no additional threat for high-risk patients. Improved overall success and repeat revascularization rates may be due to better perfusion of ischemic areas not amenable to bypass. Further studies are warranted to determine whether these trends are indeed significant.
