Chronic stable angina transmyocardial revascularization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

As the survival of patients with primary coronary events continue to increase, the number of patients presenting with refractory ischemia despite maximal medical therapy and unsuitable for further traditional revascularization techniques also continues to rise.[1] Transmyocardial revascularization (TMR) is one of the emerging techniques that has been studied in many randomized trials and has shown to reduce the incidence of recurrent angina, increase exercise tolerance time and improve quality of life.[1][2] TMR can be performed using either a laser beam or a percutaneous approach. However, only laser TMR is currently FDA approved.

Transmyocardial Revascularization

Mechanism of Benefit

Direct myocardial revascularization involves a series of transmural endo-myocardial channels through the heart muscle that carries blood from the ventricular cavity into the myocardium to improve myocardial revascularization.[3] Following TMR, the outside of the heart muscle seals up immediately. In time, as these channels heal, they stimulate the creation of new small vessels or capillaries (angiogenesis). Other mechanism of benefit in TMR is thought to be sympathetic denervation.[4][5][6]

Prognosis

  • Across various studies, researchers have found that the mortality rates range from 5 to 20% and the peri-operative mortality ranges between 5 to 12%.[7][8][9][10][11][12]
  • In a small subset of studies, researchers found different stages of wound healing in human nonresponder myocardium after TMR. This, they concluded, resulted in scarred tissue that displayed capillary network and dilated venules without evidence of patent and endothelialized laser-created channels.[13][7]

Approach

  • TMR could be performed using either a carbon dioxide or holmium: YAG laser known as laser TMR or by a percutaneous approach with a catheter referred as percutaneous TMR.
  • Another way to perform TMR is through epicardial surgical approach. This can be done alone or in combination with CABG.[14]

Indication

Transmyocardial revascularization is an alternative procedure for patients with severe refractory angina who remain symptomatic despite receiving maximal medical therapy and/or refractory patients with normal to mildly reduced left ventricular function and who are unsuitable for revascularization with either PCI or CABG.

Disadvantages

  • Although it has been hypothesized that TMR induced angiogenesis caused improved myocardial perfusion, there is no evidence that the procedure would alter the left ventricular performance, which is often the result of clinically significant improved myocardial perfusion.[15]
  • Animal studies suggest that TMR has been has been shown to partially denervate the cardiac nerve fibers.[16]

Supportive Trial Data

  • The six randomized trials that compared TMR with medical therapy in patients with refractory angina, demonstrated significant clinical benefit associated with TMR; however, the extent of improvement varied and myocardial perfusion was improved only in five of the six trials.
  • Percutaneous transmyocardial laser revascularisation has shown to be associated with an increased exercise tolerance time, lower morbidity rates, lower angina scores, and improved quality of life.[17][18]
  • Laser TMR was shown to provide significant symptomatic benefit but no improvement in the exercise capacity.[7]
  • Patients with refractory angina who underwent laser TMR and received continued medical therapy, demonstrated a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related re-hospitalization.[19][8]
  • In the DIRECT trial, 298 patients with severe angina and unsuitable for CABG or PCI, were randomly assigned to receive either low-dose or high-dose myocardial laser channels or no laser channels, and blinded as a control procedure. The study demonstrated that treatment with percutaneous myocardial laser revascularization provided no benefit in comparison to continued medical therapy in terms of clinical outcome, quality of life and improvement in exercise duration.[20]

ACC/AHA Guidelines- Laser Transmyocardial Revascularization (DO NOT EDIT)[21][22]

Class IIa
"1. Surgical laser transmyocardial revascularization (TMR). (Level of Evidence: A)"

2011 ACCF/AHA/SCAI Guidelines: Transmyocardial Revascularization to Improve Symptoms (DO NOT EDIT)[3]

Class IIb
"1. Transmyocardial laser revascularization performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting. [10][7][2][23][24] (Level of Evidence: B)"

References

  1. 1.0 1.1 Kim MC, Kini A, Sharma SK (2002) Refractory angina pectoris: mechanism and therapeutic options. J Am Coll Cardiol 39 (6):923-34. PMID: 11897431
  2. 2.0 2.1 Burkhoff D, Schmidt S, Schulman SP, Myers J, Resar J, Becker LC et al. (1999) Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal Therapies in Comparison. Lancet 354 (9182):885-90. PMID: 10489946
  3. Roethy W, Yamamoto N, Burkhoff D (1999) An examination of potential mechanisms underlying transmyocardial laser revascularization induced increases in myocardial blood flow. Semin Thorac Cardiovasc Surg 11 (1):24-8. PMID: 9930708
  4. Yamamoto N, Kohmoto T, Gu A, DeRosa C, Smith CR, Burkhoff D (1998) Angiogenesis is enhanced in ischemic canine myocardium by transmyocardial laser revascularization. J Am Coll Cardiol 31 (6):1426-33. PMID: 9581745
  5. Kwong KF, Kanellopoulos GK, Nickols JC, Pogwizd SM, Saffitz JE, Schuessler RB et al. (1997) Transmyocardial laser treatment denervates canine myocardium. J Thorac Cardiovasc Surg 114 (6):883-9; discussion 889-90. PMID: 9434682
  6. Horvath KA, Smith WJ, Laurence RG, Schoen FJ, Appleyard RF, Cohn LH (1995) Recovery and viability of an acute myocardial infarct after transmyocardial laser revascularization. J Am Coll Cardiol 25 (1):258-63. PMID: 7798512
  7. 7.0 7.1 7.2 7.3 Aaberge L, Nordstrand K, Dragsund M, Saatvedt K, Endresen K, Golf S et al. (2000) Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris. Clinical results from the Norwegian randomized trial. J Am Coll Cardiol 35 (5):1170-7. PMID: 10758957
  8. 8.0 8.1 Frazier OH, March RJ, Horvath KA (1999) Transmyocardial revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease. N Engl J Med 341 (14):1021-8. DOI:10.1056/NEJM199909303411402 PMID: 10502591
  9. Lange RA, Hillis LD (1999) Transmyocardial laser revascularization. N Engl J Med 341 (14):1075-6. DOI:10.1056/NEJM199909303411410 PMID: 10502599
  10. 10.0 10.1 Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T et al. (1999) Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial. Lancet 353 (9152):519-24. PMID: 10028979
  11. Nägele H, Stubbe HM, Nienaber C, Rödiger W (1998) Results of transmyocardial laser revascularization in non-revascularizable coronary artery disease after 3 years follow-up [ssee comments.] Eur Heart J 19 (10):1525-30. PMID: 9820991
  12. Burkhoff D, Wesley MN, Resar JR, Lansing AM (1999) Factors correlating with risk of mortality after transmyocardial revascularization. J Am Coll Cardiol 34 (1):55-61. PMID: 10399992
  13. Gassler N, Wintzer HO, Stubbe HM, Wullbrand A, Helmchen U (1997) Transmyocardial laser revascularization. Histological features in human nonresponder myocardium. Circulation 95 (2):371-5. PMID: 9008451
  14. Trehan N, Mishra Y, Mehta Y, Jangid DR (1998) Transmyocardial laser as an adjunct to minimally invasive CABG for complete myocardial revascularization. Ann Thorac Surg 66 (3):1113-8. PMID: 9769015
  15. Rimoldi O, Burns SM, Rosen SD, Wistow TE, Schofield PM, Taylor G et al. (1999) Measurement of myocardial blood flow with positron emission tomography before and after transmyocardial laser revascularization. Circulation 100 (19 Suppl):II134-8. PMID: 10567292
  16. Kwong KF, Schuessler RB, Kanellopoulos GK, Saffitz JE, Sundt TM (1998) Nontransmural laser treatment incompletely denervates canine myocardium. Circulation 98 (19 Suppl):II67-71; discussion II71-2. PMID: 9852883
  17. McGillion M, Cook A, Victor JC, Carroll S, Weston J, Teoh K et al. (2010) Effectiveness of percutaneous laser revascularization therapy for refractory angina. Vasc Health Risk Manag 6 ():735-47. PMID: 20859544
  18. Oesterle SN, Sanborn TA, Ali N, Resar J, Ramee SR, Heuser R et al. (2000) Percutaneous transmyocardial laser revascularisation for severe angina: the PACIFIC randomised trial. Potential Class Improvement From Intramyocardial Channels. Lancet 356 (9243):1705-10. PMID: 11095257
  19. Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL, Gangahar DM et al. (1999) Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med 341 (14):1029-36. DOI:10.1056/NEJM199909303411403 PMID: 10502592
  20. Leon MB, Kornowski R, Downey WE, Weisz G, Baim DS, Bonow RO et al. (2005) A blinded, randomized, placebo-controlled trial of percutaneous laser myocardial revascularization to improve angina symptoms in patients with severe coronary disease. J Am Coll Cardiol 46 (10):1812-9. DOI:10.1016/j.jacc.2005.06.079 PMID: 16286164
  21. Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980
  22. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58. PMID: 12515758
  23. Allen KB, Dowling RD, DelRossi AJ, Realyvasques F, Lefrak EA, Pfeffer TA, Fudge TL, Mostovych M, Schuch D, Szentpetery S, Shaar CJ (2000). "Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial". The Journal of Thoracic and Cardiovascular Surgery. 119 (3): 540–9. PMID 10694615. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  24. Stamou SC, Boyce SW, Cooke RH, Carlos BD, Sweet LC, Corso PJ (2002). "One-year outcome after combined coronary artery bypass grafting and transmyocardial laser revascularization for refractory angina pectoris". The American Journal of Cardiology. 89 (12): 1365–8. PMID 12062729. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)

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