Trans-myocardial revascularization by laser [TMRL] - mechanism of action and five-year follow-up

ABSTRACT

We report 5 years' follow up of Transmyocardial Revascularization by Laser [TMRL] in patients with Ischemic heart disease and propose a possible mechanism of action of TMRL. Many studies of TMRL on 'no-option' patients have been published reporting symptom relief and improvement in exercise duration, reduction in drugs required and hospitalization for up to one year duration. A Norwegian clinical trial has reported 43 months follow up. Mechanism of action of TMRL is still debatable. We studied 50 patients of Ischemic heart disease NYHA angina class III, IV who were symptomatic on maximum medical treatment, not suited for CABG, PTCA, i.e. 'no-option' patients and were offered TMRL. Their symptoms, exercise tolerance, medications and symptom-free survival were studied for 5 years. A left ventriculogram was performed after 5 years on consenting patients to identify any channels in the myocardium. We offered TMRL to50 patients of angina NYHA class III, IV [mean 3.44 +/- 0.50]. Their angina class improved to mean 1.88 +/- .74 at 6 months [p=0.00585], to 0.96 +/- 0.77 at 2 years [p = .150], and stayed at 2.06 +/- 0.80 at 5 years [p=0.019]. Their ETT mean value before operation was 5.036 +/- 1.54 minutes, at 2 years 6.56 +/- 1.79 minutes [p=7.83 E-18] and at 5 years 5.26 +/- 1.56 minutes [p=0.0002]. Kaplan Meier symptoms free survival rate was 83.1 percent at 6 months 77.3 percent at 2 years and 66.5 percent at 5 years. Left ventriculogram patients showed a meshwork of channels in the lased myocardium. Transmyocardial Revascularization by Laser provides improvement of 1-2 angina classes, quality of life perception as well as in effort tolerance in 'no-option' patients of Ischemic heart disease. The improvement is maintained beyond five years. Lased myocardium develops a network of new vascular channels which originate from left ventricular cavity