Transmyocardial holmium laser revascularization: Feasibility of a thoracoscopic approach

Objective: Creation of transmyocardial channels from the epicardium to the left ventricular cavity with the use of a laser is a modem approach in the treatment of patients with chronic ischemic heart disease unsuitable for coronary angioplasty or bypass grafting. We present the results of transmyocardial laser revascularization (TMLR) with a holmium laser as sole therapy in 22 patients operated on between November 1995 and February 1997. Methods: There were five females (23%) and 17 males (77%), with a mean age of 67 ± 7 years (range 53-74 years). Previous myocardial revascularization had been performed in 77% of the patients. Pre-operatively, 12 patients (55%) were in angina class III and ten (45%) in class IV (mean 3.5 ± 0.5); unstable angina was present in seven patients (32%). In 20 patients, TMLR was performed through a limited thoracotomy, while in two a thoracoscopic approach was used. Each patient received a mean of 33 ± 8 channels in 27 ± 13 min, while total operation lasted 130 ± 28 min. Results: There were no hospital deaths and no major post-operative complications. Mean hospital stay was 7 ± 3 days; the two patients undergoing thoracoscopic TMLR were discharged after 4 and 5 days, respectively. Two deaths were observed after 40 days and 4 months after TMLR, due to stroke and myocardial infarction. Mean follow-up of current survivors is 10 ± 6 months (range 3-15 months), with seven patients followed for over 12 months. At last follow-up, mean angina class is 1.9 ± 0.6 (P <0.001). A significant increase in exercise tolerance and a reduction of the number of hospitalizations for angina were also observed. However, no significant changes in myocardial perfusion were observed. Conclusions: The present study demonstrates that: (1) TMLR with a holmium laser yields clinical improvement in the majority of patients with severe angina unsuitable for conventional surgical treatment, (2) gratifying results in terms of improved anginal status and exercise tolerance are achieved, despite the lack of significant changes in myocardial perfusion at early follow-up and (3) TMLR through a thoracoscopic approach is a feasible procedure.