Synergy of Old and New Technology Results in Successful Revascularization of the Anterior Myocardium with Relief of Angina in the Absence of Suitable Targets

Authors

  • Robert L. Quigley

DOI:

https://doi.org/10.1532/HSF98.20041053

Abstract

Background: Diffuse and distal left anterior descending (LAD) coronary disease that is refractory to conventional surgical and/or percutaneous revascularization represents a clinical and economic dilemma. Transmyocardial laser revascularization (TMLR) has improved angina without clear measurable improvement of myocardial perfusion. This study was undertaken to determine if combining a Vineberg implant with TMLR of the LAD distribution enhances myocardial perfusion and relieves symptoms.

Methods: Twenty-one patients with an obliterated LAD and a viable anterior wall underwent off-pump coronary artery bypass grafting (OPCAB) (2.6 grafts/patient). Eight were studied with preoperative, postoperative-early (4-9 days), and postoperative-late (3-5 months) stress and rest nuclear imaging. In all but 3 cases, the Vineberg implant was modified such that the distal end of the conduit, as it emerged from the muscular tunnel, was anastomosed to any patent LAD segment. The anterior wall, to the left of the LAD, was also instrumented with a Holmium yttriumaluminum-garnet laser (8-16 sites).

Results: There has been 100% follow-up with durations ranging from 6 to 36 months. There were no deaths. All patients had complete relief of their angina. Serial perfusion scans demonstrated a 2-phase improvement in perfusion. Three of the patients underwent angiography of the implant at 6 to 9 months; angiography in each case demonstrated a patent robust conduit. The 1 patient studied at 24 months demonstrated several sites of a myocardial "blush" consistent with neovascularization.

Conclusions: Although some of the benefits of TMLR/Vineberg may be a consequence of collateral blood flow from other revascularized regions, we believe there to be a synergistic effect on perfusion and angina relief by these combined procedures which may be related to angiogenesis.

References

Quigley RL, Weiss SJ, Highbloom RY, et al. 2001. Creative arterial bypass grafting can be performed on the beating heart. Ann Thorac Surg 72:793-7.nSayeed-Shah U, Mann MJ, Martin J, et al. 1998. Complete reversal of ischemic wall motion abnormalities by combined use of gene therapy with transmyocardial laser revascularization. J Thorac Cardiovasc Surg 116:763-9.nSchofield PM, Sharples LD, Caine N, et al. 1999. Transmyocardial laser revascularization in patients with refractory angina: a randomized controlled trial. Lancet 353:515-24.nTakanashi S, Fukui T, Hosoda Y, et al. 2003. Off-pump long onlay bypass grafting using left internal mammary artery for diffusely diseased coronary artery. Ann Thorac Surg 76:635-7.nVineberg AM. 1950. The value of surgical treatment of coronary artery occlusion by implantation of the internal mammary artery into the ventricular myocardium. Surg Gynecol Obstet 91:551-61.nBurkhoff D, Schmidt S, Schulman SP, et al. 1999. Transmyocardial laser revascularization compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomized trial. Lancet 354:885-90.nEffler DB, Sones FM, Groves LK, et al. 1965. Myocardial revascularization by Vineberg's internal mammary artery implant. J Thorac Cardiovasc Surg 50:527-33.nGregoris I, Messner G, Couto WJ, et al. 2003. Off-pump coronary artery bypass grafting and transmyocardial laser revascularization. Tex Heart Inst J 30:13-8.nKawasuji M, Nagamine H, Ikeda M, et al. 2000. Therapeutic angiogenesis with intramyocardial administration of basic fibroblast growth factor. Ann Thorac Surg 69:1155-61.nMukherjee D, Deepak LB, Roe TR, et al. 1999. Direct myocardial revascularization and angiogenesis--how many patients might be eligible? Am J Cardiol 84:598-600.nPeterson ED, Kaul P, Kaczmarek RG, et al. 2003. From controlled trials to clinical practice: monitoring transmyocardial revascularization use and outcomes. JACC 2003;42:1611-6.nAllen KB, Dowling RD, DelRossi AJ, et al. 2000. Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multi-center, blinded, prospective randomized, controlled trial. J Thorac Cardiovasc Surg 119:540-9.n

Published

2005-01-04

How to Cite

Quigley, R. L. (2005). Synergy of Old and New Technology Results in Successful Revascularization of the Anterior Myocardium with Relief of Angina in the Absence of Suitable Targets. The Heart Surgery Forum, 7(5), E343-E348. https://doi.org/10.1532/HSF98.20041053

Issue

Section

Articles