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CLINICAL STUDIES

Factors correlating with risk of mortality after transmyocardial revascularization

Daniel Burkhoff, MD, PhD^*, Margaret N. Wesley, PhD, Jon R. Resar, MD, FACC and Allan M. Lansing, MD

^* Department of Medicine, Columbia University, New York, New York, USA
Information Management Services, Inc, Silver Spring, Maryland, USA
Department of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
Audubon Heart Center, Louisville, Kentucky, USA

Manuscript received March 6, 1998; revised manuscript received February 9, 1999, accepted March 19, 1999.

Reprint requests and correspondence: Dr. Daniel Burkhoff, Department of Medicine, Columbia University, 630 West 168^th Street, New York, New York 10032
db59{at}columbia.edu

OBJECTIVES

The purpose of this study was to determine factors correlating with the risk of postoperative mortality after transmyocardial laser revascularization (TMR).

BACKGROUND

Clinical studies have indicated that TMR reduces angina by an average of two classes in patients with medically refractory symptoms not treatable by coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty. Factors which correlate with mortality after TMR, however, have not been extensively investigated.

METHODS

One hundred thirty-two patients with severe angina underwent TMR as sole therapy with a CO₂ laser. Age, gender, ejection fraction, prior CABG, unstable angina and the severity of coronary artery disease (graded on the basis of a newly proposed Anatomic Myocardial Perfusion index, AMP) were each determined. Each vascular territory (left anterior descending artery [LAD] left circumflex artery and posterior descending artery [PDA]) was graded as either having (AMP = 1) or not having (AMP = 0) blood flow through an unobstructed major vessel in the territory. Univariate and multivariate analysis determined which factors correlated with mortality.

RESULTS

Patients with at least one AMP = 1 vascular territory (overall AMP = 1) had a 5% (4/82) postoperative mortality rate (POM), compared with 25% (12/49) with overall AMP 0 (p = 0.002). Left anterior descending artery AMP (p = 0.03) and previous CABG (p = 0.04) each correlated with the risk of POM. However, multivariate analysis indicated that no factor improved the correlation obtained with overall AMP by itself. With regard to overall mortality (Kaplan-Meier curves), univariate analysis also revealed correlations with overall AMP (p < 0.001), LAD AMP (p = 0.005), previous CABG (p = 0.003) and PDA AMP (p = 0.05) each individually correlated with mortality. Multivariate analysis indicated that overall AMP = 1, female gender and previous CABG together correlated best with lower postoperative mortality.

CONCLUSIONS

Patients with good blood flow to at least one region of the heart through a native artery or a patent vascular graft have a markedly reduced risk of perioperative and longer term mortality.

Abbreviations and Acronyms   AMP = Anatomic Myocardial Perfusion index   CABG = coronary artery bypass graft   EF = ejection fraction   LAD = left anterior descending artery   TMR = transmyocardial revascularization

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