Technique of transmyocardial revascularization: avoiding complications in high-risk patients.

BACKGROUND

Transmyocardial revascularization (TMR) is an emerging therapy for coronary artery disease, with 7 years of published clinical research and nearly three years of clinical application. Every report thus far has confirmed that TMR relieves severe angina pectoris. It is primarily an alternative therapy for angina which has been refractory to conventional medical and surgical treatment. Operative mortality of 3% to 10% has been reported.

METHODS

Seventy-seven patients were treated with TMR using a Holmium: YAG laser. Admission criteria included severe angina despite high doses of at least two anti-angina medications and nitroglycerin, reversible ischemia by thallium scan, and unsuitability for CABG or angioplasty. Patients had end-stage ischemic heart disease and multiple previous conventional procedures. TMR was performed through small left anterior thoracotomies using a 10.16 cm or less incision.

RESULTS

Seventy-five patients recovered from surgery without major complications. One patient (1.3%) died of an autopsy-proven myocardial infarction in the treated region, and two additional patients had a myocardial infarction (4.3%). Four patients had paresis of the left phrenic nerve, as determined by an elevated left hemi-diaphragm on chest X-ray, from which three recovered fully. Patients had no bleeding or wound infections. Patients were intubated for an average of 1.5 hours and remained in ICU an average 0.8 days. Mean hospitalization was 3.4 days.

CONCLUSIONS

Technically well-done TMR through a small anterior thoracotomy can have good therapeutic results and low morbidity and mortality. We will describe operative techniques which minimize pain and stress and help to insure surgical success.