激光心肌再血管化早期临床效果观察

TransmyocardialLaserRevascularization--PreliminaryClinicalTrial

选择３例不能做冠状动脉搭桥和经皮腔内血管成形术并且药物治疗无效的冠心病心绞痛病人行激光心肌再血管化（ＴＭＬＲ），观察其疗效，并对ＴＭＬＲ的临床效果作出评价。经左第４或第５肋间前外侧切口显露心脏，使用ＨＬ－１００心脏激光治疗仪作心肌打孔并经食管超声监测激光打孔情况。打孔部位在左室游离壁缺血区，３冽病人心肌打孔数目分别为２３、２７和２０个。手术时间为１２０±２０分。未发生与ＴＭＬＲ相关的并发症。术后１～６个月内随访检查心电图、平板运动试验、超声心动图（ＵＣＧ）和心肌放射性核素断层扫描（ＳＰＥＣＴ）。术后病人均无心绞痛发生。２例于ＴＭＬＲ术后１～３个月做平板运动试验，运动时间均比术前延长；３例做ＵＣＧ示静息状态下室壁动度均有所增加，但左室射血分数与术前相比无明显变化，１例做多巴酚丁胺－ＵＣＧ示注射少量多巴酚丁胺对心室壁动度的增强作用比术前明显，并且心肌对多巴酚丁胺的最大耐受量比术前增加；心肌ＳＰＥＣＴ示ＴＭＬＲ的心肌缺血区血液灌注增强，尤其在平板运动试验后更为明显。结论：ＴＭＬＲ可缓解心绞痛，改善心肌灌注，提高心脏功能，但远期临床效果需进一步观察。

Transmyocardiallaserrevascularization(TMLR),anewsurgicaltechnique.hasbeenin-vestigatedbymanyresearchers.Theoretically,TMLRcreatesmanynewtransrtyocardialchannelsal-lowingdirectperfusionoftheische.icareaofthemyocardiumbyventricularbloodflow.Uptonow,TMLRisstillinitsclinicaltrialstage.ThepreliminaryresultsofTMLRapplicaeionshowgoodprospect,butlong-termfnllow-upislacking.OurobjectivewastoevaluatethefeasibilityofTMLRasanalternativetreatmentforpatientsutnsuitableforCABGorPTCA.TMLRwasperformedin3patientswithdemnnstrablemyocardialischemiaorinfarctbycoronaryangiogramandSPECT.Twopatientswereintheanginaclass(C.C.S.3-4and1patienthaduttstableangina.Throughaleftanterolateralthoractomyinthefnurthorfifthintercostalspace,TMLRwasperformedonthebeatingheartusingCO2laser.Follow-upperiodsrangedfrorn1to6months.Postoperatively.completereliefofanginawasre-vealedinallpatier.Tc-SPECTshowedimprovedperfusionofmyocardium.Dobutaminee-chocardiographydncumentedanincreasetintheventricularwallmotionandLVEFinIpatientascom-paredwithbateline.TheaveragetreadmilltoleranceandtheaverageRPPatpeakstresswerealsosignificantlyincreasedascomparedwithbaselinevalues.Conclusions,TMLRimprovesanginalstatus,myocardialperfusion,andcardiacfunction.ltmaybeanalternativemodalityforthetreatmentofis-chernicheartdisease.