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TMLR: Evaluation of the ney revasularization method by determining objective parameters of perfusion and contractility
Abstract
Objectives: For patients with severe angina, in whom PTCA or CABG is impossible, a new Laser treatment technique (transmyocardial laser revascularization=TMLR) has been used for revascularization. Methods: Between 9/95 and 2/96 TMLR was performed in 14 male patients (mean age 68.0±5.5 years) who had demonstrable ischemia in viable myocardium. Preoperative 11/14 patients (79%) had an MI and 9/14 patients (64%) underwent previous CABG. LV-EF was 46% on average. The mean Canadian Cardiovascular Society (CCS) angina class was 3.6±0.6. All patients are followed by PET, 201-TI-SPECT or Tc99m-Sestamibi scan, echo, exercise tolerance test, clinical status and ventriculography - preoperative, 4 and 12 months after operation. Perioperative Swan Ganz catheter - investigations were performed. Results: In 4/14 patients (36%) a combined procedure (TMLR and aortocoronary bypass operation) has been done. In these cases 12.3 microchannels and in the solitary procedures (TMLR in 64%) 28 microchannels per patient (on average) were achieved. One week after operation (n=13) mean CCS angina class was to 2.5±0.8 (p<0.05). At 4 month, (n=6), mean CCS angina class decreased to 1.8±0.6 (p<0.05). Resting perfusion and metabolic, echocardiographic and MUGA-scan- studies did not represent statistically significant change over baseline (p=ns). In contrast average treadmill tolerance and the average maximal exertion were both significantly increased. Conclusions:This study indicates that the treatment with TMLR relieves symptoms and increases treadmill tolerance. Further systematic follow-up will show if myocardial perfusion and contractility will improve. Experimental porcine studies to explain the mechanism of TMLR are in progress.
... TMLR creates transmural channels in ischemic viable myocardium via laser ablation [1]. Multicenter, as well as single center [2,3], reports have documented significant symptomatic improvement in these patients. Results of measurements of regional myocardial perfusion have indicated a significant improved perfusion of the TMLR treated ischemic areas [2,4]. ...
Does perioperative use of the intraaortic balloon pump (IABP) improve the postsurgical outcome of patients presenting with endstage coronary artery disease, unstable angina and low ejection fraction transferred for transmyocardial laser revascularization (TMLR)?
TMLR, as sole therapy combined with the perioperative use of an intraaortic balloon pump has been assessed in seven patients with endstage coronary artery disease, unstable angina and low ejection fraction (EF < 35%). Six out of seven patients had signs of congestive heart failure. These patients are compared with 23 patients with endstage coronary artery disease, stable angina and EF > 35%, who were treated with TMLR as sole therapy without the use of IABP. The creation of transmural channels was performed by a CO2-laser. All patients were evaluated by hybrid positron emission tomography (perfusion SPECT and viability PET) and ventriculography preoperatively. Echocardiography, clinical status and hemodynamic assessment by Swan Ganz catheter were performed perioperatively.
The perioperative mortality of this combined procedure (TMLR and IABP) was zero. Three out of seven patients had pneumonia with complete recovery. Swan Ganz catheter examinations showed deterioration of LV-function after TMLR intraoperatively and improvement after 2 h and further after 6 h on ICU (P < 0.05). In contrast, a decrease of LV-function in sole TMLR patients with an EF > 35%) has not been observed. Patients with EF < 35% needed the IABP for 2.3 days and moderate dose catecholamines for a mean of 3.0 days. The postoperative EF and resting wall motion score index (WMSI) of all analysed LV segments (evaluated by echocardiography) did not change compared to baseline (EF 31.3+/-2.6 preop. to 32.8+/-3.2 postop.; WMSI: 1.75+/-0.14 at baseline to 1.71+/-0.17 postop.). The average Canadian Angina Class at the time of discharge decreased from 4.0+/-0 (baseline) to 2.3+/-0.5 (P < 0.05) and the NYHA-Index from 3.9+/-0.3 to 2.7+/-0.5. No patient had signs of angina pectoris, whereas two patients still had signs of congestive heart failure.
The reported data support our concept to start IABP preoperatively in patients with reduced LV contractile reserve in order to provide cardiac support during the postoperative phase of reversible decline of LV-function induced by TMLR.
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