Secondary Transmyocardial Laser Revascularization in the Treatment of End-stage Coronary Artery Disease

Krabatsch, Thomas; Tambeur, L.; Lieback, E.; Hetzer, Roland

doi:10.1111/j.1540-8191.1998.tb01240.x

“…Prior to the randomized studies, mortality rates in the 10% to 20% 7‐13 range were reported for TMR patients. In the randomized trials, lower perioperative mortality rates were reported ranging from 1 to 5% 14‐20 .…”

Section: Resultsmentioning

confidence: 99%

“…Since the Food and Drug Administration (FDA) approval in 1998, over 20,000 TMR procedures have been performed in the United States and over 50,000 worldwide. Results from individual institutions, multicenter studies, and prospective randomized controlled trials have been reported 7‐20 …”

mentioning

confidence: 99%

Transmyocardial Laser Revascularization

Horvath

¹

2008

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It has been almost a decade since transmyocardial laser revascularization (TMR) was approved for clinical use in the United States. The safety of TMR was demonstrated initially with nonrandomized studies in which TMR was used as the only treatment for patients with severe angina. TMR efficacy was proven after multiple randomized controlled trials. These revealed significant angina relief compared to maximum medical therapy in patients with diffuse coronary disease not amenable to conventional revascularization. In light of these results, TMR has been used as an adjunct to coronary artery bypass grafting (CABG). By definition, patients treated with this combined therapy have more severe coronary disease and the co morbidities that are associated with end stage athorosclorosis. Combination CABG + TMR has resulted in symptomatic improvement without additional risk. The likely mechanism whereby TMR has provided benefit is the angiogenesis engendered by the laser-tissue interaction. Improved perfusion and concomitant improvement in myocardial function has been observed post TMR. Additional therapies to enhance the angiogenic response include combining TMR with stem cell based treatments which appear to be promising future endeavors.

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“…They reported that although Frazier et al [34] demonstrated a 20% increase in myocardial perfusion, Allen et al [38] showed no significant change when compared to medical management. Furthermore two other papers showed increases in perfusion with thallium scans [40, 41] while three others reported no change [34], [42, 43]. Together, these findings contribute conflicting evidence and inconsistency towards efforts to determine whether or not TMR promotes angiogenesis and/or increased myocardial perfusion.…”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes meta-analysis: measuring subendocardial perfusion and efficacy of transmyocardial laser revascularization with nuclear imaging

Iwanski

¹

,

Knapp

²

,

Avery

³

et al. 2017

J Cardiothorac Surg

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IntroductionRandomized and nonrandomized clinical trials have tried to assess whether or not TMR patients experience an increase in myocardial perfusion. However there have been inconsistencies reported in the literature due to the use of different nuclear imaging modalities to test this metric. The primary purpose of this meta-analysis was to determine whether SPECT, MUGA and PET scans demonstrate changes in myocardial perfusion between lased and non-lased subjects and whether laser type affects myocardial perfusion. The secondary purpose was to examine the overall effect of laser therapy on clinical outcomes including survival, hospital re-admission and angina reduction.MethodsSixteen studies were included in the primary endpoint analysis after excluding all other non-imaging TMR papers. Standardized mean difference was used as the effect size for all quantitative outcomes and log odds ratio was used as the effect size for all binary outcomes.ResultsStatistically significant improvements in myocardial perfusion were observed between control and treatment groups in myocardial perfusion at 6-month follow up using PET imaging with a porcine model. However non-significant differences were observed in patients at 3 and 12 months using SPECT, PET or MUGA scans. Both CO2 and Ho:YAG laser systems demonstrated an increase in myocardial perfusion however this effect was not statistically significant. In addition both laser types displayed statistically significant decreases in patient angina at 3, 6 and 12 months but non-significant increases in survival rates and decreases in hospital re-admissions.ConclusionIn order to properly assess myocardial perfusion in TMR subjects, subendocardial perfusion needs to be analyzed via nuclear imaging. PET scans can provide this level of sensitivity and should be utilized in future studies to monitor and detect perfusion changes in lased and non-lased subjects.

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“…Prior to the randomized studies, mortality rates in the 10-20% [7][8][9][10][11][12][13] range were reported for TMR patients. In the randomized trials, lower perioperative mortality rates were reported ranging from 1-5% [14][15][16][17][18][19][20].…”

Section: Results: Sole Therapy Mortalitymentioning

confidence: 99%

“…Additionally, the presence of diseased but non-grafted arteries carries a poor prognosis and poses a significant negative influence leading to an increased incidence of death, recurrent angina, myocardial infarction, and the need for repeat CABG [4][5][6] over 20,000 TMR procedures have been performed in the United States and over 50,000 worldwide. Results from individual institutions, multi-center studies and prospective randomized controlled trials have been reported [7][8][9][10][11][12][13][14][15][16][17][18][19][20].…”

Section: Introduction Historymentioning

confidence: 99%

Transmyocardial Laser Revascularization

Horvath¹

Contemporary Cardiology

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It has been almost a decade since transmyocardial laser revascularization (TMR) was approved for clinical use in the United States. The safety of TMR was demonstrated initially with nonrandomized studies in which TMR was used as the only treatment for patients with severe angina. TMR efficacy was proven after multiple randomized controlled trials. These revealed significant angina relief compared to maximum medical therapy in patients with diffuse coronary disease not amenable to conventional revascularization. In light of these results, TMR has been used as an adjunct to coronary artery bypass grafting (CABG). By definition, patients treated with this combined therapy have more severe coronary disease and the co morbidities that are associated with end stage athorosclorosis. Combination CABG + TMR has resulted in symptomatic improvement without additional risk. The likely mechanism whereby TMR has provided benefit is the angiogenesis engendered by the laser-tissue interaction. Improved perfusion and concomitant improvement in myocardial function has been observed post TMR. Additional therapies to enhance the angiogenic response include combining TMR with stem cell based treatments which appear to be promising future endeavors.

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Secondary Transmyocardial Laser Revascularization in the Treatment of End-stage Coronary Artery Disease

Cited by 8 publications

References 11 publications

Transmyocardial Laser Revascularization

Transmyocardial Laser Revascularization

Clinical outcomes meta-analysis: measuring subendocardial perfusion and efficacy of transmyocardial laser revascularization with nuclear imaging

Transmyocardial Laser Revascularization

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