ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Giuseppe Poletti
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dato, G. M. A.
Right arrow Articles by Poletti, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dato, G. M. A.
Right arrow Articles by Poletti, G.
Related Collections
Right arrowRelated Article

Ann Thorac Surg 2000;69:1993-1994
© 2000 The Society of Thoracic Surgeons

Correspondence

TMR and CABG: the best way to obtain a complete and a more lasting revascularization?

Guglielmo M. Actis Dato, MDa, Merzad Hakimpour, MDa, Massimo Bacciega, MDa, Michele di Summa, MDa, Giuseppe Poletti, MDa

a Azienda Ospedaliera, San Giovanni Battista di Torino, Cardiochirurgia Universitaria, C. so Dogliotti, 14, 10126 Torino, Italy

e-mail: actisdato{at}hotmail.com

To the Editor

Transmyocardial revascularization (TMR) has been recently approved to be a safe and effective method in case of recurrent angina after a previous direct revascularization or in case of aggressive progression of the coronary disease with contraindication to bypass or percutaneous transluminal coronary angioplasty procedures. A clinical improvement in Canadian class of TMR patients is a well-known result when compared with medical therapy alone [1]. Reading the excellent paper by Agarwal and colleagues [2] and the interesting invited commentary by March in which a combined TMR plus coronary artery bypass graft procedure in case of limited native coronary bed is indicated in order to reduce perioperative risk, we would add our personal experience.

We started a TMR program in 1996, and since this date 20 patients (13 males; mean age 66 ± 0.7 years) received a surgical procedure using an Holmium:YAG laser (Eclipse 2000). Our policy was to propose and to perform TMR only in patients with a Canadian class III to IV and with no indications to receive a direct revascularization (Table 1). In our series, clinical results were comparable with the literature but perfusion test did not show a significative improvement at follow-up. Nevertheless, we observed the following significative case.


View this table:
[in this window]
[in a new window]
  		Table 1. Patient Characteristics and Clinical Results With the Holmium:YAG Laser (Eclipse 2000)

 
A 69-year-old female with an history of hypertension and diabetes was admitted to our hospital with a Canadian class III. The angiographic study showed a triple-vessel disease with a diffuse coronaropathy. The patient was informed regarding the high risk and the very poor late patency expectation with a bypass procedure. A TMR was proposed, but not persuaded, and the patient received a three bypass (left anterior descending with internal thoracic artery, circumflex branch and right coronary with saphenous vein). One year later, because of a recurrent angina at rest, the patient was admitted again at our hospital, and had a new coronarography. Clinical condition at admission was worse (Canadian class IV) with EKG modifications, and a continuous intravenous infusion of nitrates and heparin was necessary.

A diffuse coronary disease similar to the prebypass study and a patency of both arterial and venous graft but a reduced run-off possibly due to the microvessel disease was present. A TMR was then performed after a scintigraphic basal evaluation (Fig 1). The procedure, performed in the usual manner, was uneventful and the patient was discharged 7 days after intervention in Canadian class I. A perfusion scan with Tallium was then performed 4 months after surgery and revealed a complete absence of deficit after stress (Fig 2).



View larger version (89K):
[in this window]
[in a new window]
  		Fig 1. Perfusion Tallium scan performed in basal conditions before TMR.

 


View larger version (91K):
[in this window]
[in a new window]
  		Fig 2. Perfusion Tallium scan after exercise 4 months after TMR.

 
It was interesting to observe that during the TMR procedure, from the holes, a black desaturate blood came out. Our question was: "Why did blood poor of oxygen come out from the left ventricle in which was present a 150 PaO2?" In other cases, we observed a blood suffusion that was more red and, therefore, more oxygen saturated. A possible answer to this observation is that the lesions produced by the laser in the peripheral vessels might improve the run-off of native vessels and the open graft. Also, the oxygen extraction from the ischemic muscle can produce a desaturated bleeding from the surface of the heart. The idea that the holes can carry the blood from the left ventricle to the myocardium seems to be leaven; in fact, during the systole, the myocardium wall resistance to the flow can not facilitate a blood diffusion in the muscle from the holes. At the same time, a facilitated diffusion of the blood from a bypass can be possible after the resistance reduction produced by the laser.

In conclusion, we agree with the idea that a combined effect of direct revascularization associated with TMR should be effective to improve perfusion and to reduce operative risk in a large patient population affected by diffuse coronary disease, and this can be more true in cases in which a microvessel disease is present (ie, diabetes).

References

  1. March R.J. Transmyocardial laser revascularization with the CO2 laser. Semin Thorac Cardiovasc Surg 1999;11:12-18.[Medline]
  2. Agarwal R., Ajit M., Kurian V.M., Rajan S., Arumugam S.B., Cherian K.M. Transmyocardial laser revascularization. Ann Thorac Surg 1999;67:432-436.[Abstract/Free Full Text]

Related Article

Reply
Ravi Agarwal, N. Madhu Sankar, Mullasari Ajit, and Kotturathu M. Cherian
Ann. Thorac. Surg. 2000 69: 1995. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 Card Surg AdultHome page
K. A. Horvath and Y. Zhou
Transmyocardial Laser Revascularization and Extravascular Angiogenetic Techniques to Increase Myocardial Blood Flow
Card. Surg. Adult, January 1, 2008; 3(2008): 733 - 752.
[Full Text]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Giuseppe Poletti
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dato, G. M. A.
Right arrow Articles by Poletti, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dato, G. M. A.
Right arrow Articles by Poletti, G.
Related Collections
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS