Combined Transmyocardial Laser Revascularization Research Articles

A DECADE OF EXPERIENCE IN APPLICATION OF TRANSMYOCARDIAL LASER REVASCULARIZATION IN COMBINATION WITH AORTOCORONARY SHUNTING

Objective: to study the security and the effect of transmyocardial laser revascularization in combination with aortocoronary shunting in patience with diffuse coronary artery disease.Materials and methods: the study compared the results of surgical treatment in patients with diffuse distal coronary artery disease in the period from 2007 to 2013. Patients were divided into two groups, the first group consisted of patients who underwent CABG in combination with TMLR (n-60), the second group includes patients who underwent isolated CABG (n-46). According to the initial demographic data and comorbidity, the groups were not significantly different from each other. Subsequent observation (on average 7, 5±0, 9 years) included rating of survival and return of angina. Results: remote mortality during the observation period in the first group was 7, 6 % (n = 4), and in the second group — 18, 9 % (n = 7). In both groups the functional class of angina pectoris significantly decreased, however, in the first group this tendency was more expressed (exertional angina I EF in the CABG + TMLR group have 54 (90 %) patients, in the second group — 33 (71,7 %), p = 0,02. Conclusions: transmyocardial laser revascularization in combination with aortocoronary shunting in high-risk patients with diffuse atherosclerotic lesions of the coronary arteries contributed to an increase in exercise tolerance, reduced symptoms, and provided an acceptable quality of life in the long term.

Long-term results of isolated transmyocardial laser revascularization in combination with the intramyocardial autologous bone marrow stem cells injection.

To evaluate the long-term results of TMLR using a CO2 laser in combination with intramyocardial injection of ABMSC as an isolated procedure in patients with the end-stage coronary artery disease, the study included 20 patients (90% male), with a mean age of 58.4 ± 8.7 years. To assess the long-term results, patients were examined in a hospital. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Seattle Angina Questionnaire (SAQ) were used. The evolution of laboratory and instrumental indices, as well as medical therapy, was assessed. The end points of the study were death, acute myocardial infarction (AMI), repeated myocardial revascularization, recurrent hospitalizations due to coronary artery disease, and stroke. The changes in angina functional class were also evaluated. The median of follow-up period was 54 (36; 83) months, that is, 4.5 years. The analysis of the evolution of echocardiographic data showed the absence of statistically significant changes in the following parameters: left ventricular end-diastolic diameter (EDD) (p = 0.967), end-systolic diameter (ESD) (p = 0.204), end-diastolic volume (EDV) (p = 0.852), end-systolic volume (ESV) (p = 0.125), and left ventricular ejection fraction (LVEF) (p = 0.120). The patients continued to regularly take the main groups of medications. Nitrate consumption was significantly reduced (p < 0.001). Significant positive dynamics were observed in the changes in angina functional class. At the baseline, all patients had angina III FC, in the long term, 3 patients had II FC, 11 patients had I FC, and 6 patients had no angina. Clinical outcomes (mortality, recurrent myocardial infarction, stroke) were absent during the follow-up period. There were two cases of repeated myocardial revascularization. Regression analysis revealed that SYNTAX score was associated with the clinical outcome "repeated revascularization." TMLR in combination with intramyocardial injection of ABMSC is a safe method to achieve a statistically significant antianginal effect and reduce the need for "nitrates," which in turn improves the quality of life and reduces the frequency of hospitalizations due to coronary artery disease. These results can be achieved with strict adherence to the certain indications for the intervention.

Отдаленные результаты операций изолированной трансмиокардиальной лазерной реваскуляризации в сочетании с интрамиокардиальным введением аутологичных стволовых клеток костного мозга

Введение. В настоящее время во всем мире активно внедряются альтернативные методы лечения ишемической болезни сердца (ИБС) и используются в ситуациях, когда не представляется возможным выполнить прямую реваскуляризацию миокарда. Среди них трансмиокардиальная лазерная реваскуляризация (ТМЛР), введение аутологичных стволовых клеток костного мозга (АСККМ). Чтобы достичь «синергизма» ТМЛР с интрамиокардиальным введением АСККМ, оба метода комбинировали.

Autologous Bone Marrow-Derived Stem Cell Therapy in Combination with TMLR. A Novel Therapeutic Option for Endstage Coronary Heart Disease: Report on 2 Cases

We report 2 cases in which patients with coronary heart disease not amenable for conventional revascularization underwent transmyocardial laser revascularization (TMLR) and implantation of AC133+ bone-marrow stem cells. The reason for using TMLR in combination with stem cell application is to take advantage of the synergistic angiogenic effect. The local inflammatory reaction induced by TMLR should serve as an informational platform for stem cells and may trigger their angiogenic differentiation. Functional analysis of myocardial performance after treatment in these 2 cases revealed dramatic improvement of the wall motion at the site of the TMLR and stem cell application. Because TMLR does not enhance myocardial contractility and there was no angiographic evidence of major collaterals to the ischemic region in either patient, we assume that the synergistic effect of stem cells and TMLR-induced angiogenesis occurred; however, our assumption is of a speculative nature. We think that TMLR in combination with stem cell transplantation might become a novel revascularization therapy for ischemic myocardium.

Transmyocardial laser revascularization in combination with coronary artery bypass: Clinical, wall motion and perfusion effects

Background. Transmyocardial laser revascularisation (TMR) is increasingly used in the management of intractable angina in the absence of graftable vessels, however it’s role in combination with coronary artery bypass remains undefined. The aim of this pilot study was to investigate the impact of the combination therapy.

Transmyocardial laser revascularization.

Low-powered lasers were first used in the early 1980s to produce transventricular channels as an adjunct to coronary artery bypass graft surgery (CABG). Early results were encouraging, but because of the combined procedure, could not be attributed directly to use of the laser [1]. High-powered lasers were introduced into clinical practice in 1990 [2]. These lasers are powerful enough to create a transmyocardial channel with minimal thermal damage to surrounding tissues [3]. Clinical studies, using transmyocardial laser revascularization (TMR) as the sole operative therapy for patients with severe and diffuse coronary artery disease (CAD) who have Class III or IV angina, and are on medical therapy, have been conducted since 1993. Based on the results of these studies, the FDA granted approval for the use of TMR as a sole therapy. Clinical studies are currently underway to assess the results of combined TMR and CABG [4]. Results of four controlled randomized studies have been published [5-8]. The data from two of these studies formed the basis for FDA approval of two different types of laser systems. The results of these studies have not provided any additional insights into the mechanism of action of TMR, which remains the Achilles' heel of this procedure. In this review, background information about the TMR procedure will be discussed along with an analysis of the recently published randomized studies.

Partial left ventriculectomy combined with transmyocardial laser revascularization

We report the use of transmyocardial laser revascularization in combination with partial left ventriculectomy for treatment of end-stage dilated ischemic cardiomyopathy. The disappearance of the reversible perfusion defects in the treated left ventricular territories and improvement of the systolic function led us to believe that the simultaneous use of these two techniques was complementary in our patient.

Combined TMR and Mitral Valve Replacement via Left Thoracotomy

Transmyocardial laser revascularization is an emerging technique for treatment of patients with coronary artery disease not amenable to standard revascularization by either percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Transmyocardial laser revascularization is typically performed as an isolated procedure on the beating heart, although it has been performed as an adjunct to conventional coronary artery bypass grafting in nongraftable territories. We report the use of transmyocardial laser revascularization in combination with mitral valve replacement via a left lateral thoracotomy for treatment of ischemic mitral regurgitation.