Transmyocardial revascularization in patients with refractory, unstable angina

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Medical Technology

Background:

• Transmyocardial revascularization (TMR) has shown high mortality in prior reports for refractory, unstable angina patients.
• Patients in this study were defined as unstable if they required intravenous antianginal medications or were too unstable for a persantine thallium scan.
• All patients presented with class IV angina and were not candidates for conventional revascularization (CABG or PTCA).

Purpose of the Study:

• To evaluate the efficacy and safety of holmium laser transmyocardial revascularization (TMR) in patients with refractory, unstable angina.
• To determine if TMR could provide significant angina relief with acceptable mortality in this challenging patient subset.

Main Methods:

• Holmium laser TMR was performed on 85 patients with a mean of 35 laser channels.
• Patient characteristics included a mean age of 63 years, LVEF > 25% (mean 48%), 79% male, 87% with prior revascularization, and 72% with a history of myocardial infarction.
• Follow-up assessments measured angina class and mortality at 3, 6, and 12 months post-procedure.

Main Results:

• Operative mortality was 12% (10 of 85). Total 12-month mortality was 22.4% (19 of 85).
• Significant angina relief was observed: at 3 months, 86% of patients had class II angina or better; at 12 months, 75% had class II or better.
• Mean angina class improved from baseline (class IV) to 1.5-1.6 at 6 and 12 months.

Conclusions:

• Holmium laser TMR is an effective treatment for significant angina relief in patients with refractory, unstable angina.
• The 30-day operative mortality and 12-month mortality were acceptable given the severe condition of the patient population.
• TMR offers a viable therapeutic option for patients ineligible for traditional revascularization procedures.