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Ann Thorac Surg 1999;68:1203-1209
© 1999 The Society of Thoracic Surgeons

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Original Articles

Transmyocardial laser revascularization in the patient with unmanageable unstable angina

^a University of Pittsburgh, Pittsburgh, Pennsylvania, USA
^b San Francisco Heart Institute, San Francisco, California, USA
^c Heart and Lung Institute of Wisconsin, Milwaukee, Wisconsin, USA
^d Brigham and Women’s Hospital, Boston, Massachusetts, USA
^e Texas Heart Institute, Houston, Texas, USA
^f Columbia-Audubon Hospital, Louisville, Kentucky, USA
^g Northwestern University, Chicago, Illinois, USA
^h Cedars-Sinai Medical Center, Los Angeles, California, USA
ⁱ Duke University Medical Center, Durham, North Carolina, USA
^j Washington Hospital Center, Washington, DC, USA

Address reprint requests to Dr Hattler, Division of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, C-700 Presbyterian University Hospital, 200 Lothrop St, Pittsburgh, PA 15213

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

Background. Transmyocardial laser revascularization (TMR) provides relief for patients with chronic angina, nonamenable to direct coronary revascularization. Unmanageable, unstable angina (UUA) defines a subset of patients with refractory angina who are at high risk for myocardial infarction and death. Patients were classified in the UUA group when they had been admitted to the critical care unit with unstable angina for 7 days with three failed attempts at weaning them off intravenous antianginal medications.

Methods. Seventy-six treated patients were analyzed to determine if TMR is a viable option for patients with unmanageable unstable angina. These patients were compared with 91 routine protocol patients (protocol group [PG]) undergoing TMR for chronic angina not amenable to standard revascularization. The procedure was performed through a left thoracotomy without cardiopulmonary bypass. These patients were followed for 12 months after the TMR procedure. Both unmanageable and chronic angina patients had a high incidence of at least one prior surgical revascularization (87% and 91%, respectively).

Results. Perioperative mortality ( 30 days post-TMR) was higher in the UUAG versus PG (16% vs 3%, p = 0.005). Late mortality, up to 1 year of follow-up, was similar (13% vs 11%, UUAG vs PG; p = 0.83). A majority of the adverse events in the UUAG occurred within the first 3 months post-TMR, and patients surviving this interval did well, with reduced angina of at least two classes occurring in 69%, 82%, and 82% of patients at 3, 6, and 12 months, respectively. The percent improvement in angina class from baseline was statistically significant at 3, 6, and 12 months. A comparable improvement in angina was found in the protocol group of patients.

Conclusions. TMR carried a significantly higher risk in unmanageable, unstable angina than in patients with chronic angina. In the later follow-up intervals, however, both groups demonstrated similar and persistent improvement in their angina up to 12 months after the procedure. TMR may be considered in the therapy of patients with unmanageable, unstable angina who otherwise have no recourse to effective therapy in the control of their disabling angina.

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