Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial.

OBJECTIVE: We sought to assess the safety and efficacy of transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone. METHODS: A total of 263 patients whose standard of care was coronary artery bypass grafting and who had one or more ischemic areas not amenable to bypass grafting were prospectively randomized to receive coronary bypass of suitable vessels plus transmyocardial revascularization to areas not graftable (n = 132) or coronary bypass alone with nongraftable areas left unrevascularized (n = 131). Group preoperative demographics and operative characteristics were similar. RESULTS: The operative mortality rate after coronary bypass/transmyocardial revascularization was 1.5% (2/132) versus 7.6% (10/131) after coronary bypass alone (P =.02). Patients undergoing both coronary bypass and transmyocardial revascularization required less postoperative inotropic support (30% vs 55%, P =.0001) and had a trend toward fewer insertions of intra-aortic balloon pumps (4% vs 8%, P =.13) than did patients having coronary bypass alone. Multivariable predictors of operative mortality were coronary artery bypass alone (odds ratio, 5.3; 95% confidence interval, 1.1-25.7; P =.04) and increased age (odds ratio, 1.1; 95% confidence interval, 1. 0-1.2; P =.03). One-year Kaplan-Meier survival (95% vs 89%, P =.05) and freedom from major adverse cardiac events defined as death or myocardial infarction (92% vs 86%, P =.09) favored the combination of coronary bypass and transmyocardial revascularization. Baseline to 12-month improvement in angina and exercise treadmill scores was similar between groups. CONCLUSIONS: In a prospective, randomized, multicenter trial, transmyocardial revascularization combined with coronary artery bypass grafting in patients not amenable to complete revascularization by coronary bypass alone was safe; however, angina relief and exercise treadmill improvement were indistinguishable between groups at 12 months of follow-up. Operative and 1-year survival benefits observed after adjunctive transmyocardial revascularization require confirmation by a larger validation study, which is ongoing.

Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina.

BACKGROUND: Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society). METHODS: In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients). RESULTS: After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning. CONCLUSIONS: Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Coronary artery bypass after recent myocardial infarction.

During a five-year period, 280 patients underwent myocardial revascularization within 60 days of having suffered an acute myocardial infarction. Eighty-six percent of them had angina. Twelve patients had calculated ejection fractions of less than 20%; 79, 21% to 40%; and 105, from 41% to 60%. Ten patients had one graft; 33, two; 74, three; and 163, four or more. Twenty-four patients had concomitant ventricular aneurysm repair. The intra-aortic balloon pump was used in only seven patients. There was one postoperative death secondary to respiratory insufficiency and sepsis, resulting in a hospital mortality of 0.4%. Myocardial revascularization is a safe procedure following recent myocardial infarction, with results comparable to elective revascularization. Our long-term results suggest that revascularization may decrease the incidence of recurrent myocardial infarction.

Improved operative risk after myocardial revascularization.

At Ochsner Medical Institutions from 1970 to 1979, 96 patients who had previously had myocardial revascularization later had a total of 136 noncardiac operations. There were no postoperative myocardial infarctions and only one noncardiac death. Transitory postoperative arrhythmias occurred in 3.6% of patients. It appears that myocardial revascularization protects the cardiac patient from myocardial infarction and cardiac-related deaths during and after noncardiac operations. Patients with cardiac disease scheduled for elective surgery should have exercise testing or coronary cineangiography or both to evaluate the severity and significance of the coronary disease. If significant coronary lesions are demonstrated that are amenable to a bypass procedure, the operative risk will be lessened by prior revascularization.

Delayed pulmonary complications of ventricular aneurysm repair. Report of two cases and review of the literature.

Two patients referred to Ochsner Foundation Hospital after ventricular aneurysm repair had the delayed pulmonary complications of massive hemoptysis and bronchiectasis. Only three cases of infected ventricular aneurysm repair have been reported previously. The felt buttress used in aneurysm repair may be the seat of indolent infection or it may erode into pulmonary tissue with secondary infection. For anatomic reasons the lingular segment of the lung appears to be at increased risk of involvement. Symptoms led to the correct diagnosis in one case at 7 months and in the other at 3 years after the original operation. Infection may be prevented by appropriate measures. However, should such a catastrophe occur, aggressive surgical therapy with removal of all foreign material is mandatory.

Current surgical management of pheochromocytoma during pregnancy.

The diagnosis of pheochromocytoma during pregnancy has rarely been made correctly prior to delivery, only 42 cases having been reported. Antepartum diagnosis markedly decreases the maternal and fetal mortality. We report a case of pheochromocytoma manifesting during the third trimester of pregnancy. Preoperative control of blood pressure with phenoxybenzamine and phentolamine therapy was carried out. Simultaneous cesarean section and excision of the tumor resulted in a healthy mother and newborn infant. We review the perioperative and intraoperative management of patients with a pheochromocytoma during pregnancy.

Clinical spectrum of pulmonary hamartomas.

Pulmonary hamartomas are tumors that occur in the parenchyma or the bronchi. Through the lesions themselves are benign, they may be associated with malignant neoplasms or they may cause obstruction of the bronchi because of their location. Pulmonary hamartomas were resected in 29 patients at the Ochsner Medical Institutions during a 30-year period. Of these patients, 6 had symptoms related to concomitant malignancy and 3 had symptoms resulting from obstruction of the bronchi by the hamartoma. Surgical treatment ranged from enucleation to pneumonectomy. One patient died in the hospital of extensive bronchogenic carcinoma. In 2 others, carcinoma of the lung developed within twelve months after resection of a hamartoma. In this group of patients, 20% had concomitant or subsequent pulmonary lesions. Ten percent of the hamartomas were located in the bronchi, resulting in bronchial obstruction. A surgical approach is indicated for lesions that appear to be pulmonary hamartomas on roentgenograms.

Surgical experience with postinfarction ventricular aneurysm.

Fifty-eight patients had surgical treatment of postinfarction ventricular aneurysm. Resection was performed in 47 patients and plication in 11. There were 44 combined procedures, mostly myocardial revascularizations. Indications for operation included congestive heart failure, angina, arrhythmias, and thromboembolic phenomena. All aneurysms were documented by cineventriculography, and 54 patients had coronary cineangiograms. Left ventricular end diastolic (LVED) pressures ranged from 25 to 50 in 25 of the patients but did not affect mortality. Hospital mortality (14% overall) was directly proportional to degree of coronary artery disease--single vessel, 0; double vessel, 10%; triple, 24%. Nine patients are alive more than six months postoperatively and 37 are alive from six months to eight years postoperatively. We conclude that aneurysmectomy is the procedure of choice for ventricular aneurysms that are hemodynamically significant or have produced ventricular clots, arrhythmias, or embolic phenomena. An LVED of greater than 25 mm Hg does not contraindicate operation, but triple vessel coronary disease increases the risk.