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Transmyocardial laser as an adjunct to minimally invasive CABG for complete myocardial revascularization
Insights
This study combined coronary artery bypass grafting without cardiopulmonary bypass with transmyocardial laser revascularization for high-risk patients. The technique safely achieved complete myocardial revascularization, significantly improving angina-free status and exercise tolerance.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Procedures
- Interventional Cardiology
Background:
- Diffuse coronary artery disease poses challenges for complete revascularization.
- Patients with severe systemic disease or aortic arteriosclerosis are at high risk for cardiopulmonary bypass.
- A combined surgical approach is needed for these complex cases.
Purpose of the Study:
- To evaluate the safety and efficacy of combining direct coronary artery bypass grafting (CABG) without cardiopulmonary bypass with transmyocardial laser revascularization (TMLR).
- To achieve complete myocardial revascularization in high-risk patients unsuitable for traditional cardiopulmonary bypass.
- To assess functional and perfusion improvements post-procedure.
Main Methods:
- A cohort of 77 high-risk patients underwent combined CABG without cardiopulmonary bypass and TMLR between April 1995 and September 1997.
- Procedures involved sternotomy or minithoracotomy, with CABG targeting the left anterior descending or right coronary artery.
- TMLR was applied to areas supplied by ungraftable or distal targets using a CO2 laser.
Main Results:
- The combined procedure was performed on 77 patients, with a mean bypass of 1.12 vessels.
- One early postoperative death occurred due to ventricular arrhythmia.
- At 12 months, 89% of patients were angina-free, with significant improvements in exercise tolerance and myocardial perfusion scans.
Conclusions:
- Transmyocardial laser revascularization serves as an effective adjunct to minimally invasive CABG for complete revascularization.
- This combined approach offers a safe alternative for high-risk patients who cannot tolerate cardiopulmonary bypass.
- The procedure demonstrates minimal morbidity and mortality, with significant long-term functional and perfusion benefits.
Background:
To achieve complete myocardial revascularization in patients with diffuse coronary artery disease and patients at high risk if they undergo cardiopulmonary bypass such as severe systemic disease or diffuse arteriosclerosis of the aorta, we have adopted the technique of combining direct coronary artery bypass grafting without cardiopulmonary bypass with transmyocardial laser revascularization.
Methods:
From April 1995 to September 1997 this technique was used in 77 patients. Ages ranged from 37 to 85 years with a mean of 56 +/- 17 years. Diffuse coronary artery lesions were present in 46 patients, 10 had severely deranged renal function, 7 had diffuse carotid artery lesions, and 7 had aortic arch atheromas. Liver dysfunction was present in 4 patients and severe obstructive airway disease in 3. The mean left ventricular ejection fraction was 0.45 +/- 0.05. Midsternotomy approach was used in 65 patients and anterior minithoracotomy in 12. Direct coronary artery bypass grafting without cardiopulmonary bypass was done to the left anterior descending coronary artery or right coronary artery or both. Transmyocardial laser revascularization using a 1,000-W CO2 laser machine was performed on the areas supplied by ungraftable coronary arteries or even in graftable distal targets in the posterolateral or inferior wall in patients who were at high risk if they underwent cardiopulmonary bypass.
Results:
The mean number of vessels bypassed was 1.12. One patient died of intractable ventricular arrhythmia in the early postoperative phase. Mean follow-up was 16.6 months. At 12 months 89% of the patients were angina free. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 at baseline to 9.7 minutes at 12 months. Myocardial thallium scanning done at 3-, 6-, and 12-month intervals postoperatively revealed that myocardial perfusion in grafted segments had an exponential trend of improvement, and perfusion in transmyocardial laser revascularization segments showed a linear trend in the same period with a total gain of 28.4%.
Conclusions:
Transmyocardial laser revascularization is an excellent adjunct to minimally invasive coronary artery bypass grafting to achieve complete myocardial revascularization in patients with graftable vessels in the anterior wall and ungraftable vessels in the posterior and inferior wall. This achieves complete myocardial revascularization without compromising safety in patients who are at high risk if they undergo cardiopulmonary bypass. Minimal morbidity and mortality in the present series revealed that this procedure is safe, and postoperative follow-up of these patients showed significant functional improvement as well as an improvement in myocardial perfusion scan.