Ann Thorac Surg 2002;73:650-652
© 2002 The Society of Thoracic Surgeons
Case report
Reoperative transmyocardial laser revascularization for late recurrent angina
Richard Lee, MDa,
Keith C. Fischer, MDb,
Marc R. Moon, MD*a
a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
b Division of Nuclear Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
Accepted for publication April 27, 2001.
* Address reprint requests to Dr Moon, Division of Cardiothoracic Surgery, Washington University School of Medicine, 3108 Queeny Tower, #1 Barnes-Jewish Plaza, St. Louis, MO 63110-1013, USA
e-mail: moonm{at}msnotes.wustl.edu
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Abstract
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Transmyocardial laser revascularization (TMR) reduces anginal class and is indicated for severely symptomatic patients who are not candidates for conventional revascularization. This report describes a 72-year-old man who presented 4 years following initially successful TMR with recurrent angina refractory to maximal medical management. Reoperative TMR was performed with substantial improvement in angina and functional class.
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Introduction
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Transmyocardial laser revascularization (TMR) for the treatment of patients with debilitating angina who are not candidates for conventional revascularization has become increasingly popular. Several randomized, prospective trials have demonstrated that TMR improves Canadian Cardiovascular Society (CCS) angina class and may improve exercise tolerance and decrease repeat hospitalization [1–4]. The improvement in angina class and functional activity has been largely maintained for more than 12 months. The current report describes a patient who presented with recurrent angina and underwent reoperative TMR 4 years after initially successful TMR.
A 75-year-old diabetic man presented to Washington University in December 2000 with CCS class IV angina. The patient had an extensive history of coronary artery disease. In 1988, the patient underwent six-vessel coronary artery bypass grafting, but in 1995, he developed recurrent, intractable angina. At that time, single photon emission computed tomography (SPECT) myocardial imaging demonstrated reversible ischemia in the lateral and posterolateral regions, while cardiac catheterization demonstrated a patent left internal mammary artery to the left anterior descending artery, but no other patent grafts or suitable target vessels. Transmyocardial laser revascularization was performed as part of an experimental protocol using a CO2 laser system. Through a left anterolateral thoracotomy, 23 laser channels were created. Postoperatively, the patient reported excellent relief of his angina with a reduction of medication and a substantial improvement in his activity for a period of 3
years.
During the 9 months prior to his recent presentation, the patient developed recurrent, progressive, severe angina requiring increasing medical therapy. Despite maximum ß-blockade, long-acting nitrate therapy, and a substantial reduction in his daily activities, he required supplemental sublingual nitroglycerin as many as 16 times per day. Cardiac catheterization again confirmed a patent left internal mammary artery graft without other patent grafts or target vessels with an ejection fraction of 25%, and SPECT myocardial imaging demonstrated a small reversible defect in the lateral wall (Fig 1).
At the persistent request of the patient, reoperative TMR was performed, again through a left anterolateral thoracotomy. Thirty-four channels were created with a Holmium:YAG laser system (Eclipse Surgical Technologies, Sunnyvale, CA). The patient felt immediate relief of his angina and was discharged home on the 4th postoperative day. At 3 months postoperatively, the patient’s angina remained markedly improved (CCS class II), he had taken sublingual nitroglycerin on only two occasions, and his ß-blockade dosage had been decreased by 50%. The patient had markedly increased his activity level, including the initiation of dance lessons with his wife.
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Fig 1. Long axis (A, B) and short axis (C, D) single photon emission computed tomography (SPECT) myocardial images obtained during adenosine stress testing. The adenosine Tc-99m Sestamibi images (A, C) both show an enlarged ventricle with a small lateral wall myocardial defect that is improved on the rest images (B, D).
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Comment
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Controversy exists regarding the mechanism of action by which TMR improves angina in patients refractory to maximal medical therapy. Denervation, angiogenesis, direct transventricular communication, and placebo have all been proposed, but as the mechanism of action of TMR remains undefined, so does its mechanism of failure in the patient presented in this report. Potentially, angina may have recurred after reinnervation of ischemic myocardium, or the patient may have developed progressive native coronary disease that was no longer addressed by his initial TMR. Regardless of the etiology, the patient’s clinical picture was similar to that with which he presented prior to his first TMR in 1995.
Reoperative TMR may represent an alternative for patients debilitated by late recurrent angina who have no other treatment options. This case represents the first reported application of reoperative TMR in a patient who had a prolonged symptom-free interval after successful TMR. In a previous report from 1998, 3 patients underwent reoperative TMR [5]. However, the longest interval from initial TMR to reoperation was 14 months, which may represent a failed primary intervention rather than the late recurrence of angina, as was the case in the patient described in this report. We are cautiously optimistic about the potential long-term result in this patient and will consider reoperative TMR in future patients who develop recurrent angina late after initially successful TMR.
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References
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Frazier O.H., March R.J., Horvath K.A., et al. Transmyocardial laser revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease. N Engl J Med 1999;341:1021-1028.[Abstract/Free Full Text]
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Allen K.B., Dowling R.D., Fudge T.L., et al. Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med 1999;341:1029-1036.[Abstract/Free Full Text]
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Burkhoff D., Schmidt S., Schulman S.P., et al. Transmyocardial laser revascularization compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomized trial. Lancet 1999;354:1995-1996.[Medline]
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Jones J.W., Schmidt S.E., Richman B.W., et al. Holmium:Yag laser transmyocardial revascularization relieves angina and improves functional status. Ann Thorac Surg 1999;67:1596-1601.[Abstract/Free Full Text]
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Krabatsch T., Tambeur L., Lieback E., Hetzer R. Secondary transmyocardial laser revascularization in the treatment of end-stage coronary artery disease. J Card Surg 1998;13:93-97.[Medline]
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Abstract
Introduction
