Transmyocardial revascularization utilizing a holmium:YAG laser.

OBJECTIVE To evaluate the efficacy of transmyocardial revascularization performed on patients with refractory class IV or unstable angina with a holmium:yttrium-aluminum-garnet laser. METHODS Transmyocardial revascularization with a holmium:yttrium-aluminum-garnet laser was performed in 42 patients with refractory angina who were not candidates for percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Patients had either Canadian Heart Association class IV angina (n = 23) or unstable angina (n = 19) and were unable to be weaned from intravenous nitroglycerin. Preoperative thallium studies identified the extent and location of reversible ischemia. Operative exposure was via a limited left anterior thoracotomy. An average of 45+/-11 laser channels were created with a mean operative time of 106+/-38 min. RESULTS Perioperative mortality was 12% (5/42) with no late deaths. Complications included ventricular 7.1% (3/42) and atrial 4.7% (2/42) arrhythmias, reoperation for chest-wall hemorrhage 2% (1/42), and respiratory failure requiring reintubation 2% (1/42). Intra-aortic balloon pump placement was required in 12% (5/42). The mean postoperative length of stay was 5.5+/-4.9 (1-25) days. Mean follow-up on 100% of patients is 5.4+/-3.0 (1-12) months. At 3 (n = 33) and 6 (n = 21) months follow-up the mean angina class was 1.5+/-0.1 (P < 0.002) and 1.1+/-0.1 (P < 0.001), respectively. CONCLUSIONS Transmyocardial revascularization utilizing a holmium:yttrium-aluminum-garnet laser resulted in a significant reduction in angina class and was beneficial in patients with refractory angina untreatable by conventional methods.