[Transmyocardial laser revascularization--limits and possibilities]

Indications for interventional catheter techniques and bypass surgery have been extended to more complex lesions and also the number of reoperations after primary successful interventions has increased due to progression of the underlying disease. Finally a number of patients remains still symptomatic but, as a consequence of a very diffuse distribution of atherosclerotic lesions, is no longer accessible with conventional techniques of direct revascularization. This has drawn the attention again to indirect techniques of myocardial revascularization. Transmyocardial laserrevascularization offers a new option in reperfusing the ischemic myocardium via transmural channels from the ventricular cavity. As to the function of the channels, it is not quiet clear, wether they may connect to intramyocardial capillaries or may themselves induce a neoangiogenesis. However the clinical follow up in patients with intractable angina pectoris shows a significant improvement. At our hospital a number of 117 patients have been treated with this new method, 53 of them in conjunction with conventional bypass surgery. Clinical follow up after three and six months postoperatively showed a significant improvement concerning angina (CCS) and exercise tolerance (NYHA). This could also objectively be demonstrated by scintigraphy with an increased myocardial perfusion in 50% of the reinvestigated patients. Ischemic areas can still be seen, but occur at a significantly higher exercise level, demonstrating an improved but not normalized myocardial blood supply. The transmyocardial laserrevascularization is no alternative to well established procedures like PTCA or bypass surgery, but can be seen as a therapeutic option for those symptomatic patients recently being intractable. Further longterm studies and also experimental investigations have to evaluate the definitive role of this new treatment for endstage coronary heart disease.