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Transmyocardial laser revascularisation combined with coronary artery bypass grafting without cardiopulmonary bypass
Insights
This study shows combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR) is a safe and effective treatment for diffuse coronary artery disease, improving patient outcomes and reducing angina.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Minimally Invasive Cardiac Procedures
Background:
- Diffuse coronary artery disease poses challenges for complete revascularization.
- Patients with severe systemic disease or aortic atherosclerosis are at high risk for cardiopulmonary bypass (CPB).
- Alternative revascularization strategies are needed for high-risk patients.
Purpose of the Study:
- To evaluate the feasibility and efficacy of combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR).
- To achieve complete myocardial revascularisation in high-risk patients with diffuse coronary artery disease.
- To assess short-term outcomes in patients undergoing TMLR + CABG without CPB.
Main Methods:
- A combined technique of CABG without CPB and TMLR using a 1000 W CO2 laser was performed on 56 patients.
- TMLR targeted ungraftable arterial regions, while CABG addressed the left anterior descending artery and/or right coronary artery.
- Patient characteristics included advanced age, renal failure, prior CABG, severe angina, and IABP support.
Main Results:
- The combined TMLR + CABG approach demonstrated a mean of 1.09 grafts per patient, with high Internal Thoracic Artery (ITA) utilization.
- Postoperative cardiac enzyme elevations (CPK-MB, Troponin T) were observed in a minority of patients.
- Mortality was low at 1.8%, with significant improvements in angina status (90.9% free at 12 months), myocardial perfusion, exercise tolerance, and Karnofsky scores.
Conclusions:
- The combined CABG and TMLR technique is surgically feasible and safe for selected high-risk patients.
- This approach offers excellent short-term results, including significant symptom relief and improved functional capacity.
- The study highlights the potential of TMLR + CABG without CPB as a viable option for diffuse coronary artery disease.
Objective:
To achieve complete myocardial revascularisation in patients with diffuse coronary artery disease, patients with inordinately high risk of cardiopulmonary bypass (CPB) like severe systemic disease or diffuse atherosclerosis of the aorta.
Methods:
We have adopted the technique of combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR) using 1000 W CO2 laser machine. TMLR is done to areas supplied by ungraftable arteries, while CABG without cardiopulmonary bypass is done to the left anterior descending artery (LAD) and/or right coronary artery (RCA). TMLR + CABG on beating heart without CPB has been performed on 56 patients. Age ranged from 37 to 81 years with a mean of 56.17. Four patients were in renal failure, two were redo CABG. Preoperatively 39.28% patients had angina class III and 10.71% had angina class IV. Four patients were on preoperative IABP support.
Results:
The mean number of grafts was 1.09. Internal thoracic artery (ITA) was used in 96.4% of the patients. Five patients showed elevation of CPK-MB, while three patients had an increase in Troponin T. Mortality was 1.8% (one patient died of intractable ventricular arrhythmia). The mean follow-up is 9.2 months. Myocardial perfusion scanning showed a stepwise improvement in reversible ischemia increasing from 52% at baseline to 91% at 12 months; 90.9% of the patients were angina free at 12 months. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 min at baseline to 9.4 min at 12 months. Metabolic equivalents (METs) increased from 4.5 at baseline to 9.4 at 12 months. The average 44% Karnofsky score preoperative also increased to 86% at 12 months.
Conclusions:
Our results indicate that the technique is surgically feasible and safe, with excellent short term results.