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CLINICAL STUDIES

Perioperative morbidity and mortality after transmyocardial laser revascularization: incidence and risk factors for adverse events

G. Chad Hughes, MD^*, Kevin P. Landolfo, MD^*, James E. Lowe, MD, FACC^*, Robin B. Coleman, RN^* and Carolyn L. Donovan, MD, FACC

^* Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA

Manuscript received August 12, 1998; revised manuscript received October 23, 1998, accepted December 15, 1998.

Reprint requests and correspondence: Dr. Carolyn L. Donovan, Box 3606, Duke University Medical Center, Durham, North Carolina 27710
Donov001{at}mc.duke.edu

OBJECTIVES

The purpose of this study was to describe the incidence and spectrum of perioperative cardiac and noncardiac morbidity and mortality after transmyocardial laser revascularization (TMR) and to identify predictors of these adverse clinical events.

BACKGROUND

Clinical studies have demonstrated the efficacy of TMR for relieving angina pectoris, although no study to date has specifically addressed the associated perioperative morbidity and mortality.

METHODS

Between October 1995 and August 1997, 34 consecutive patients with end-stage coronary artery disease (CAD) underwent isolated TMR. The majority of patients (94%) had class III or IV angina pectoris, and two patients (6%) had unstable symptoms preoperatively. Patient records were reviewed for fatal and nonfatal adverse cardiac and noncardiac events.

RESULTS

Perioperative death occurred in two patients (5.9%) due to cardiogenic shock complicating acute myocardial infarction. Perioperative cardiac morbidity occurred in 16 patients (47.1%); noncardiac morbidity was seen in 12 patients (35.3%). Preoperative unstable angina was the only variable predictive of perioperative death (p = 0.005). Cardiac (p = 0.005) and noncardiac (p < 0.001) morbidity rates were significantly higher for the initial 15 patients undergoing the procedure. Other predictors of perioperative complications included lack of postoperative treatment with a furosemide infusion (p 0.04) and preoperative unstable angina (p = 0.05).

CONCLUSIONS

Perioperative mortality in patients undergoing isolated TMR is low. Transmyocardial laser revascularization patients are at higher risk for adverse perioperative cardiac and noncardiac events, likely reflecting the lack of immediate benefit from the procedure in the setting of severe CAD. These patients merit vigilant surveillance for adverse events and aggressive medical management in the perioperative period.

Abbreviations and Acronyms   ANOVA = analysis of variance   CABG = coronary artery bypass grafting   CAD = coronary artery disease   IABP = intraaortic balloon pump   MI = myocardial infarction   MUGA = multiple gated acquisition radionuclide ventriculography   TEE = transesophageal echocardiography   TMR = transmyocardial laser revascularization

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