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Previous Volume 341:1029-1036 September 30, 1999 Number 14 Next

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ABSTRACT

Background Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society).

Methods In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients).

Results After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan–Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05; quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning.

Conclusions Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Source Information

From the Department of Cardiothoracic Surgery, St. Vincent Hospital and Indiana Heart Institute, Indianapolis (K.B.A., C.J.S.); the Department of Cardiothoracic Surgery, University of Louisville and Jewish Heart and Lung Institute, Louisville, Ky. (R.D.D.); the Department of Cardiothoracic Surgery, Terrebonne Hospital, Houma, La. (T.L.F.); the Department of Cardiothoracic Surgery, Methodist Hospital, Memphis, Tenn. (G.P.S.); the Department of Cardiothoracic Surgery, Sacred Heart Medical Center, Spokane, Wash. (S.L.S.); the Department of Cardiothoracic Surgery, Bryan Memorial Hospital, Lincoln, Nebr. (D.M.G.); the Department of Cardiothoracic Surgery, Tampa General Hospital, Tampa, Fla. (W.W.A.); St. Thomas Heart Institute, Nashville (M.R.P.); and the Division of Cardiology, William Beaumont Hospital, Royal Oak, Mich. (W.W.O.). Presented at the American Heart Association's 71st Scientific Session, Dallas, November 7–10, 1998.The centers and investigators participating in the study are listed in the Appendix.

Address reprint requests to Dr. Allen at 8333 Naab Rd., Suite 300, Indianapolis, IN 46260, or at cvsurgeon{at}iquest.net.

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Extract | Full Text  
N Engl J Med 2000; 342:436-438, Feb 10, 2000. Correspondence

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