Efficacy of transmyocardial laser revascularization and thoracic sympathectomy for the treatment of refractory angina.

Abstract

Transmyocardial laser revascularization (TMR) is an effective treatment for relief of refractory angina. This benefit may be mediated by increase in myocardial perfusion or by cardiac denervation. We investigate the efficacy of TMR and thoracic sympathectomy (TS) for relief of angina and whether any clinical benefit is associated with enhanced myocardial perfusion. Twenty consecutive patients with nonrevascularizable coronary arteries and intractable angina were prospectively randomized to have TMR by holmium: yttrium aluminum garnet laser or TS. Subjects were clinically evaluated before, and for 42 months after, surgery. They underwent exercise tolerance testing and rest and stress quantitative perfusion magnetic resonance imaging (MRI) before, and 6 months after surgery. The demographics of the two groups were similar. There was no perioperative mortality; however, two patients died in the TS group during follow-up. The Canadian Cardiovascular Society angina score improved from 3.4 +/- 0.5 to 2.6 +/- 1.1 (p = 0.06) in the TS group at 6 months but returned to 3.2 +/- 0.7 at 42 months, while in the TMR group it improved from 3.6 +/- 0.5 to 1.9 +/- 0.7 (p = 0.008) at 6 months and deteriorated to 2.5 +/- 0.9 (p = 0.01) after 42 months of surgery. The TMR-treated patients showed significant improvements in the SF-36 scores and Seattle Angina Questionnaire only at 6 months, whereas TS-treated patients did not show amelioration at any time during follow-up. The MRI protocol was completed in 15 of 20 (TMR = 8; TS = 7) patients and no significant differences in qualitative or quantitative perfusion variables were demonstrated in either group. A greater clinical benefit was obtained with TMR than with TS early after surgery but this clinical effect did not seem to be associated with improvement in myocardial perfusion as assessed by MRI and part of the beneficial effect was lost by 42 months after surgery.