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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.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
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.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Approximately 6 million people in the U.S. suffer from angina. Through changes in lifestyle, pharmacological therapy, and, when necessary, surgical and medical revascularization procedures, the majority of these patients obtain sufficient relief from their angina to remain productive and avoid repeated hospitalizations. For patients who are refractory to medical therapy and in whom various approaches to revascularization are not possible because of failed prior procedures, diffuse coronary atherosclerosis, distal stenosis, or small coronary arteries, recurrent disabling angina constitutes a serious and frustrating dilemma to patients, physicians, and healthcare systems nationwide.

The introduction, therefore, of any new therapy to treat this patient population and to alleviate its main symptom of angina should be seriously evaluated for its impact on patient outcomes. To this extent, transmyocardial laser revascularization (TMR) was introduced by Mirhoseini and associates in 1986 after earlier experimental work demonstrating that myocardial channels could be created in the myocardium with a CO₂ laser that reportedly connected the left ventricular cavity with sinusoidal spaces within the myocardium [1]. This potential vascular network would thus provide a direct communication from the ventricular cavity to the ischemic tissue. After a phase I trial demonstrating safety in the use of a high-powered, pulsed CO₂ laser in creating these myocardial channels in humans, a phase II multicenter trial was initiated in 1992. Results from this study have been reported to provide dramatic relief of chronic disabling angina in patients on maximal medical therapy who are not considered suitable candidates for either medical or surgical revascularization [2]. A controlled, randomized study of TMR compared with maximum medical management in patients with class 3 and 4 angina was initiated in September 1995. This study further demonstrated the procedure’s effectiveness in relieving angina and increasing myocardial perfusion [3]. We have sought to determine if laser-created transmural myocardial channels provide a comparable degree of anginal relief in incapacitated patients with unmanageable, unstable angina as compared with patients with chronic angina, and with what associated mortality and morbidity.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
The study population consisted of 76 patients with unmanageable unstable angina (unmanageable unstable angina group [UUAG]) and 91 patients with chronic angina (protocol group [PG]) treated with TMR as sole therapy at the following medical centers in the U.S. beginning in June 1995: University of Pittsburgh, Pittsburgh, PA; San Francisco Heart Institute, San Francisco, CA; Heart and Lung Institute of Wisconsin, Milwaukee, WI; Brigham and Women’s Hospital, Boston, MA; Texas Heart Institute, Houston, TX; Columbia-Audubon Hospital, Louisville, KY; Rush Presbyterian-St. Luke’s Medical Center, Chicago, IL; Columbia Presbyterian Medical Center, New York, NY; Northwestern University, Chicago, IL; Cedars-Sinai Medical Center, Los Angeles, CA; Duke University Medical Center, Durham, NC; The Cleveland Clinic Foundation, Cleveland, OH; and Washington Hospital Center, Washington, DC. The analysis includes all data recorded as of March 1999. Mortality and morbidity data were available for all patients treated with TMR.

The protocol was approved by each institution’s review board (IRB) and informed consent was obtained from all patients. All PG patients met those criteria established in earlier studies, including: 1) chronic angina poorly responsive to medical therapy; 2) a level of angina that would allow thorough preoperative evaluation with radionuclide myocardial perfusion scans; 3) reversible ischemia demonstrated by these radionuclide perfusion scans; 4) severe diffuse coronary artery disease; and 5) in the majority of cases, previous percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) procedures, but now considered end-stage coronary disease with contraindications to further medical or surgical revascularization or transplantation. All UUAG patients had to have been admitted to an intensive or critical care unit (ICU or CCU) with refractory angina for 7 days with three failed attempts at weaning them off intravenous antianginal medications before being taken to the operating room for laser revascularization. Also, the majority of these patients were unable to undergo stress thallium testing because of their very fragile cardiovascular status, which prevented their meeting the criteria for enrollment into any randomized study protocol. All patients in both groups had been under maximally tolerated medical therapy, including beta-blockers, calcium antagonists, aspirin, nitrates, and, for those hospitalized, intravenous heparin, and nitroglycerine.

The patient demographics are depicted in Table I. Preoperatively, 100% of the patients in the UUAG were in Canadian cardiovascular angina class IV, whereas 80% of the patients in the PG had class IV angina and 20% had class III angina. In the UUAG, 38% of patients had an ejection fraction (EF) less than 45%. This did not reach statistical significance when compared with the 32% of patients in the PG with a similar level of myocardial dysfunction (p = 0.48). Not enough radionuclide scans were available preoperatively in the UUAG to provide a statistically significant number for postoperative comparisons. Rest and stress nuclear medicine perfusion scans were therefore not included, but have been reported for the recently completed randomized study [3]. The primary end points for this study therefore were anginal relief, mortality, and morbidity.

The carbon dioxide laser device (The Heart Laser; PLC Medical Systems, Milford, MA) has been described [6] and was used at an average pulse energy of 42 ± 10 J and a pulse width of 52 ± 12 ms. With the laser placed against the epicardium, the device was activated on the "R" wave of the electrocardiogram and through-and-through penetration to the left ventricular cavity was confirmed by TEE. Only confirmed laser holes were considered in the analysis. For PG patients, 30 ± 9 channels, and for UUAG patients, 33 ± 10 channels, were created with approximately one channel per square centimeter for each treated area. The ventricular septum was not treated by TMR. There was no statistical difference in the number of channels created between the two groups (p = 0.93).

Follow-up
As part of this study, patients were followed for 3, 6, and 12 months after the procedure, at which time their physical status and angina class were determined.

Statistics
The statistical analysis of this patient population has been described [6]. Treatment efficacy was assessed by comparing, for each patient, follow-up to baseline findings. Patients with chronic angina were compared with patients with unmanageable, unstable angina, and the angina class in the two study groups was compared before and at follow-up after the procedure using the two-sided Wilcoxon signed-rank test. Normally distributed continuous variables were analyzed using two-sided paired t tests. When necessary, a Bonferroni correction for repeated measures at multiple time points was used. Statistical significance was at the p < 0.05 level with results expressed, unless otherwise noted, as the mean ± standard deviation.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Mortality
Mortality rates in the perioperative interval (0 to 30 days) for protocol patients with chronic disabling angina (3%) were significantly different than in patients with unmanageable unstable angina (16%) (p = 0.005). However, after the first month after TMR, the mortality in the two groups was similar for those patients who entered the long-term period (31 to 365 days) (11% PG vs 13% UUAG) (p = 0.832) (Table 2). A survival curve representing the time to death (Fig 1) for UUAG patients indicates that an estimated 72% survive through 12 months. The causes of early and late deaths and the time of death after TMR are listed in Table 3. Most deaths were from cardiac causes, especially if sudden deaths are included as cardiac in origin, which is likely in this population of end-stage coronary artery disease patients. Three patients in the UUAG died on the day of surgery, 1 from ventricular fibrillation, 1 from hyperkalemia, and 1 from profound shock and arrhythmias in the operating room. This latter patient had suffered a myocardial infarct preoperatively.

View larger version (13K): [in this window] [in a new window]   Fig 1. Survival curve representing time to death for unmanageable unstable angina patients through 12 months of follow-up.

View larger version (20K): [in this window] [in a new window]   Fig 2. The incidence of Canadian Cardiovascular Society (CCS) class III and IV angina for the UUAG and for the PG out to 12 months of follow-up are depicted. The actual numbers of patients at each time interval are listed.

View larger version (22K): [in this window] [in a new window]   Fig 3. The incidence of CCS class 0 and class 1 angina in two groups is listed with the number of patients at each time interval.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Unstable angina is considered a complex clinical entity representing a nonhomogeneous set of patients frequently difficult to define [9–11]. Various attempts have been made to classify patients considered to have unstable angina [11, 12]. With the exception of recurrent angina after myocardial infarction, the wide spectrum of presenting symptoms and the extent of coronary disease represented under the heading of "unstable angina" have made it difficult to correlate the patient’s unstable anginal state with clinical prognosis [11–14]. In spite of the heterogeneous group of patients included under the heading of unstable angina, a working definition of unstable angina encompasses that group of patients who have persistent ST segment changes in their electrocardiogram and/or symptoms of refractory angina while on maximum, state-of-the-art medical therapy, including beta-blockers, calcium antagonists, aspirin, intravenous nitrates, heparin, and on occasion, intraaortic balloon counterpulsation. For patients with unmanageable, unstable angina who have suitable coronary anatomy to undergo either medical or surgical revascularization, the relief of angina is commonly dramatic, albeit at a surgical mortality that is significantly higher than that in patients operated on with chronic stable angina [15–17].

There are no studies in this era of modern medical management detailing the natural history of patients with unmanageable, unstable angina whose coronary arteries are not amenable to revascularization [12]. Earlier studies, however, have indicated that persistent angina refractory to intensive medical therapy defines a subset of patients at high risk for both myocardial infarction and death [17, 18]. Gazes and associates, in a study on the prognosis of medically treated patients with unstable angina, reported a 20% 30-day mortality and a 43% death rate at 1 year. A patient population that may provide indirect information on the natural history of very unstable anginal syndromes during the modern era of medical therapy are those patients suffering from non-Q-wave myocardial infarcts where the infarct-related artery is usually not totally occluded [19]. Some authors have suggested that there is a link between unstable angina pectoris and non-Q-wave myocardial infarction [20]. These patients are considered at high risk for recurrent ischemic events [21]. Studies where data on the long-term outcome of medically treated patients with non-Q-wave myocardial infarcts is available report a 2-year mortality rate of 19% and recurrent anginal events in 62% of these patients during follow-up [22]. There are no data in the literature on the survival of patients with unmanageable, unstable angina when treated medially with state-of-the-art therapy as it exists in the 1990s. Cardiologists who continue to define this select population of patients, however, maintain their ongoing clinical concern because of what they perceive as excessively high mortality rates in patients with unmanageable, unstable angina (personal communication, Braunwald E, Conti R). A significant difference in early mortality after TMR was observed when comparing patients with chronic angina with those with unmanageable, unstable angina (3% vs 16%, p = 0.005). This difference disappeared when follow-up extended past 30 days (PG [11%] vs UUAG [13%], p = 0.83]. From a procedural standpoint, the TMR surgery was the same for the two patient groups, and the demographics of the two groups were similar. One obvious reason for the significantly higher perioperative mortality observed in the unmanageable, unstable angina patients was that patients in the protocol group were suffering from chronic angina at the time of TMR surgery, whereas for the very unstable anginal patients, TMR surgery was preceded by 7 days of unstable angina with three failed attempts at weaning these patients off antianginal medications. The impact of angina instability on perioperative mortality associated with TMR surgery is further underscored by data from the recently completed randomized trial comparing transmyocardial laser revascularization with maximum antianginal medical therapy [3]. Within the medically treated control group, there was a population of patients who developed episodes of unstable angina and crossed over to TMR surgery. Failure of medical management was defined as at least one episode of admission to a hospital ICU or CCU for intravenous antianginal treatment. Early surgical mortality in this cross-over group (15%) was significantly higher than in patients who had chronic angina (3%). Perioperative mortality increased as the time between the unstable anginal event requiring intravenous antianginal medications and the need to cross over to TMR surgery decreased. The high early mortality figures for cross-over patients (15%) are similar to those patients with unmanageable, unstable angina (16%) as defined in our patient population. An obvious difference between TMR and coronary artery bypass graft (CABG) patients is the fact that patients undergoing direct revascularization of the coronary arteries derive an immediate, more physiological, and significant increase in myocardial blood flow. In contrast, the beneficial effect of TMR, which avoids the coronary arteries altogether, on blood flow to the myocardium is frequently difficult to document early, but may increase with time, indicating a process possibly dependent on neovascularization. With the documented assurance that TMR does significantly improve angina in both chronic and unmanageable, unstable angina patients, a debate has ensued over the possible mechanism(s) responsible for this effect. Five theories have been proffered: (1) Laser channels directly perfuse the myocardium by connecting the left ventricular cavity with a vascular network of intramyocardial sinusoids not unlike the reptilian model of the circulation. (2) Laser channels and the associated tissue ablation denervate the ischemic area of the myocardium with a resultant loss of afferent pain stimuli. (3) Laser therapy destroys viable cardiac tissue thereby enhancing the available blood supply by improving the supply/demand ratio. (4) Laser injury and its associated inflammatory response stimulates neoangiogenesis. This new vessel growth may occur not only in the treated areas, but throughout the heart. (5) Laser surgery performed for poorly controlled angina is not unlike any other surgery where pain is a dominant preoperative symptom, and a "placebo" effect may play a role in the improvement in pain after the procedure.

With none of these theories having been proven or rejected, the possibility exists that more than one mechanism is responsible for the symptomatic relief of angina. Various mechanisms may also be operative at different time intervals. Thus, psychosomatic effects are generally greatest early after a procedure, but tend to diminish with time. Early direct perfusion of blood to the myocardium has been demonstrated by some investigators and challenged as a possible operative mechanism by others [23, 24]. The fact that anginal relief tends to persist and even improve with time has prompted a search for angiogenesis in response to the associated inflammatory response after injury. Finally, myocardial denervation as the etiology of anginal relief has recently been studied experimentally, where the destruction of afferent nerve fibers has been documented after laser treatment of the canine heart [25].

Despite the fact, therefore, that the mechanism(s) for the improvement in angina after TMR are unknown, promising clinical results have been obtained in all the initial clinical trials, including the recently completed randomized trials comparing TMR with medical therapy [3]. This warrants a continued evaluation and understanding of this therapy in selected patients who are refractory to medical management and have no other options available to them. These recommendations may now be considered in patients with unmanageable, unstable angina who otherwise have no recourse to any effective therapy. The early mortality, however, can be significantly improved if these patients can be stabilized before the procedure.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Brack G. Hattler Bartley P. Griffith Marco A. Zenati Mahmood Mirhoseini Lawrence H. Cohn Sary F. Aranki Denton A. Cooley Keith A. Horvath Gregory P. Fontana Kevin P. Landolfo James E. Lowe Steven W. Boyce Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hattler, B. G. Articles by Boyce, S. W. Search for Related Content PubMed PubMed Citation Articles by Hattler, B. G. Articles by Boyce, S. W.