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Transmyocardial Laser Revascularization Using A Thoracoscopic Approach
Transmyocardial Laser Revascularization Using a Thoracoscopic Approach Aldo Milano,
MD,
ransmyocardial revascularizaT tion (TMR) with laser is aimed to increase myocardial perfusion in patients with symptomatic coronary artery disease in whom coronary anatomy is not suitable for conventional myocardial revascularization either by percutaneous transluminal coronary angioplasty or coronary artery bypass grafting.1,2 TMR is usually performed after direct exposure of the heart through a left anterolateral thoracotomy; we report the first case of TMR with a holmium laser accomplished through a thoracoscopic approach. •••
A 53-year-old man underwent coronary bypass surgery in April 1994; the left internal mammary artery was grafted to the left anterior descending artery, while saphenous vein segments were grafted to the right coronary artery and to the obtuse marginal and first diagonal branches in sequential fashion. Two years later he was readmitted for class III angina; repeat coronary angiography documented progression of coronary artery disease with occlusion of the sequential graft, multiple stenoses of the venous graft to the right coronary artery, and a patent mammary artery with a poor distal runoff. Scintigraphic studies showed reversible ischemia in the anterolateral wall of the left ventricle with an ejection fraction of 45%. ‘‘Redo’’ coronary artery bypass surgery was considered not feasible and the patient was scheduled for TMR. At operation the patient was prepared as for an anterolateral thoracotomy, with standard moniFrom the Departments of Cardiac Surgery and General and Experimental Surgery, University of Pisa Medical School, Pisa, Italy. Dr. Bortolotti’s address is: U.O. Cardiochirurgia, Ospedale Cisanello, Via Paradisa 2, 56122 Pisa, Italy. Manuscript received January 16, 1997; revised manuscript received and accepted April 14, 1997.
538
©1997 by Excerpta Medica, Inc. All rights reserved.
Andrea Pietrabissa,
MD,
and Uberto Bortolotti,
toring and double lumen orotracheal intubation. A transesophageal echocardiographic probe was inserted. The operation was performed with the aid of thoracoscopic instrumentation inserted through 3 small ports in the anterolateral thoracic wall. Under thoracoscopic vision pleural adhesions were dissected to allow access to the pericardial cavity. The pericardium was incised anterior to the phrenic nerve and after adhesions were dissected it was suspended with single stitches pulled through the thoracic wall. Dissection was limited to the anterolateral and apical left ventricular walls and previous grafts and major subepicardial coronary branches were identified. TMR was performed using a holmium laser (Eclipse Surgical Technologies, Inc., Sunnyvale, California). The standard 1-mm TMR probe was inserted alternatively through each of the thoracic ports allowing treatment of the anterior and apical left ventricular walls (Figure 1) while the flexible probe, with the aid of a special right-angled guide (‘‘J grip’’), was used to reach the more lateral aspect of the left ventricle. A total of 34 com-
MD
plete channels were created, each of them controlled by simultaneous 2-D transesophageal echocardiography. The procedure, which lasted approximately 3 hours, was well tolerated without any complication and the patient was extubated after 4 hours. The postoperative course was uneventful and he was discharged on postoperative day 5; 2 months after TMR, at clinical evaluation, he is in functional class 1. •••
TMR is a new technique aimed to provide direct perfusion of ischemic myocardium by creating a series of channels between the left ventricular cavity and the myocardium with a laser beam.2 Early results using a carbon dioxide laser indicate that TMR allows relief of angina and may improve myocardial perfusion in patients not amenable to standard methods of revascularization.3,4 Surgery is performed through a limited left anterior thoracotomy without the aid of extracorporeal circulation. In November 1995, a clinical trial of TMR using a newly developed holmium laser was started at our institution; as of November 1996 16 patients were treated with this tech-
FIGURE 1. Thoracoscopic view showing the fiberoptic probe performing transmyocardial channels.
0002-9149/97/$17.00 PII S0002-9149(97)00417-7
nique. In the last patient of this series, described in the present report, TMR was performed through a thoracoscopic approach, which has been previously described in a few patients who underwent TMR with a carbon dioxide laser.5 In the present case this approach was greatly facilitated by the use of the holmium laser, in which the laser beam is transmitted through a flexible lightweight optical fiber that
can be easily handled and manipulated through the thoracic ports. This report demonstrates that TMR with a holmium laser can be easily and safely performed through a thoracoscopic approach.
1. Mirhoseini M, Cayton MM. Revascularization of
the heart by laser. J Microsc Surg 1981;2:253– 460. 2. Smith JA, Dunning JJ, Parry AJ, Large SR, Wall-
work J. Transmyocardial laser revascularization. J Cardiac Surg 1995;10:569 –572. 3. Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmair KH, Pehlivanoglu S, Kolff JW, Wilansky S, Moore WH. Transmyocardial laser revascularization: clinical experience with twelve-month followup. J Thorac Cardiovasc Surg 1996;111:791–799. 4. Horvath KA, Mannting F, Cummings N, Sherman SK, Cohn LH. Transmyocardial laser revascularization: operative technique and clinical results at two years. J Thorac Cardiovasc Surg 1996;111: 1047–1053. 5. Vincent JG, Bardos P, Druse J, Maass D. Transmyocardial CO2 laser revascularization: from anterolateral thoracotomy to the endoscopic and minimal invasive approach. Abstracts of the 1996 Symposium on TMLR, San Diego, April 1996.
CASE REPORTS
539
MD,
ransmyocardial revascularizaT tion (TMR) with laser is aimed to increase myocardial perfusion in patients with symptomatic coronary artery disease in whom coronary anatomy is not suitable for conventional myocardial revascularization either by percutaneous transluminal coronary angioplasty or coronary artery bypass grafting.1,2 TMR is usually performed after direct exposure of the heart through a left anterolateral thoracotomy; we report the first case of TMR with a holmium laser accomplished through a thoracoscopic approach. •••
A 53-year-old man underwent coronary bypass surgery in April 1994; the left internal mammary artery was grafted to the left anterior descending artery, while saphenous vein segments were grafted to the right coronary artery and to the obtuse marginal and first diagonal branches in sequential fashion. Two years later he was readmitted for class III angina; repeat coronary angiography documented progression of coronary artery disease with occlusion of the sequential graft, multiple stenoses of the venous graft to the right coronary artery, and a patent mammary artery with a poor distal runoff. Scintigraphic studies showed reversible ischemia in the anterolateral wall of the left ventricle with an ejection fraction of 45%. ‘‘Redo’’ coronary artery bypass surgery was considered not feasible and the patient was scheduled for TMR. At operation the patient was prepared as for an anterolateral thoracotomy, with standard moniFrom the Departments of Cardiac Surgery and General and Experimental Surgery, University of Pisa Medical School, Pisa, Italy. Dr. Bortolotti’s address is: U.O. Cardiochirurgia, Ospedale Cisanello, Via Paradisa 2, 56122 Pisa, Italy. Manuscript received January 16, 1997; revised manuscript received and accepted April 14, 1997.
538
©1997 by Excerpta Medica, Inc. All rights reserved.
Andrea Pietrabissa,
MD,
and Uberto Bortolotti,
toring and double lumen orotracheal intubation. A transesophageal echocardiographic probe was inserted. The operation was performed with the aid of thoracoscopic instrumentation inserted through 3 small ports in the anterolateral thoracic wall. Under thoracoscopic vision pleural adhesions were dissected to allow access to the pericardial cavity. The pericardium was incised anterior to the phrenic nerve and after adhesions were dissected it was suspended with single stitches pulled through the thoracic wall. Dissection was limited to the anterolateral and apical left ventricular walls and previous grafts and major subepicardial coronary branches were identified. TMR was performed using a holmium laser (Eclipse Surgical Technologies, Inc., Sunnyvale, California). The standard 1-mm TMR probe was inserted alternatively through each of the thoracic ports allowing treatment of the anterior and apical left ventricular walls (Figure 1) while the flexible probe, with the aid of a special right-angled guide (‘‘J grip’’), was used to reach the more lateral aspect of the left ventricle. A total of 34 com-
MD
plete channels were created, each of them controlled by simultaneous 2-D transesophageal echocardiography. The procedure, which lasted approximately 3 hours, was well tolerated without any complication and the patient was extubated after 4 hours. The postoperative course was uneventful and he was discharged on postoperative day 5; 2 months after TMR, at clinical evaluation, he is in functional class 1. •••
TMR is a new technique aimed to provide direct perfusion of ischemic myocardium by creating a series of channels between the left ventricular cavity and the myocardium with a laser beam.2 Early results using a carbon dioxide laser indicate that TMR allows relief of angina and may improve myocardial perfusion in patients not amenable to standard methods of revascularization.3,4 Surgery is performed through a limited left anterior thoracotomy without the aid of extracorporeal circulation. In November 1995, a clinical trial of TMR using a newly developed holmium laser was started at our institution; as of November 1996 16 patients were treated with this tech-
FIGURE 1. Thoracoscopic view showing the fiberoptic probe performing transmyocardial channels.
0002-9149/97/$17.00 PII S0002-9149(97)00417-7
nique. In the last patient of this series, described in the present report, TMR was performed through a thoracoscopic approach, which has been previously described in a few patients who underwent TMR with a carbon dioxide laser.5 In the present case this approach was greatly facilitated by the use of the holmium laser, in which the laser beam is transmitted through a flexible lightweight optical fiber that
can be easily handled and manipulated through the thoracic ports. This report demonstrates that TMR with a holmium laser can be easily and safely performed through a thoracoscopic approach.
1. Mirhoseini M, Cayton MM. Revascularization of
the heart by laser. J Microsc Surg 1981;2:253– 460. 2. Smith JA, Dunning JJ, Parry AJ, Large SR, Wall-
work J. Transmyocardial laser revascularization. J Cardiac Surg 1995;10:569 –572. 3. Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmair KH, Pehlivanoglu S, Kolff JW, Wilansky S, Moore WH. Transmyocardial laser revascularization: clinical experience with twelve-month followup. J Thorac Cardiovasc Surg 1996;111:791–799. 4. Horvath KA, Mannting F, Cummings N, Sherman SK, Cohn LH. Transmyocardial laser revascularization: operative technique and clinical results at two years. J Thorac Cardiovasc Surg 1996;111: 1047–1053. 5. Vincent JG, Bardos P, Druse J, Maass D. Transmyocardial CO2 laser revascularization: from anterolateral thoracotomy to the endoscopic and minimal invasive approach. Abstracts of the 1996 Symposium on TMLR, San Diego, April 1996.
CASE REPORTS
539