激光心肌打孔血运重建术的临床应用

Clinical application of transmyocardial laser revascularization

作者对７例不能作冠状动脉搭桥和经皮冠状动脉球囊扩张、并且药物治疗无效的冠心病心绞痛患者使用国产７００瓦ＣＯ２激光器作激光心肌打孔血运重建术。７例患者心肌打孔数目１６２个，平均２４个。手术时间１５０±３０分。１例于术后第３天因呼吸衰竭死亡，其余６例术后随访２～１２个月。随访包括心绞痛级别、用药情况及心功能，并在术后３、６和１２个月检查超声心动图和心肌ＳＰＥＣＴ。结果显示：４例心绞痛消失，２例明显缓解。２例于打孔后１～６个月作平板运动试验，运动时间比术前延长，４例做超声心动图示静息状态下室壁动度均有增加，１例在术后１２个月左室射血分数由术前的４２％提高到５４％；２例做超声心动图－多巴酚丁胺检查示多巴酚丁胺对心室壁动度的作用及心肌对多巴酚丁胺的最大耐受量均比术前增强；心肌ＳＰＥＣＴ示与术前比心肌打孔区的血液灌注明显增加。作者认为：本方法作为冠心病治疗的一种新方法，可有效地缓解心绞痛，改善心肌血液灌注，提高心脏功能。

Transmyocardial laser revascularization (TMLR), a new technique, provides direct perfusion of ischemic myocardium via laser created transmural channels. From 1995 to 1996, we treated 7 patients (mean age 60 years, all men) with TMLR.Preoperatively, 5 patients were in angina class (C.C.S) 3～4 and 2 patients had unstable angina. To identify the location and extent of their reversible ischemia,the coronary angiogram, 99m SPECT and/or dobutamine echocardiography was performed before operation in 7 patients.Through a left anterior thoractomy in the fifth intehcostal space, heart exposure was gained. With the use of a 700 watt CO 2 laser, TMLR was performed on the beating heart. An average of 22±3 channels were created in 45 minutes with a total operative time of less than 2 and half hours. The in hospital mortality was one of 7 patients. Follow up ranged from 2 to 12 months (accumulated 48 patient months). Postoperatively,the relief of angina was noted in 6 patients. Postoperative SPECT and dubatamin UCG were obtained at 3, 6, and 12 months.( 99m Tc) SPECT showed a significant improvment of myocardial perfusion in the area of reversible ischemia. Dobutamin UCG documented an increase in the ventricular wall motion and LVEF in 2 patients as compared with basline.These early results indicate that TMLR may provide angina relief, improve myocardial perfusion and increase cardiac function for patients with ischemic heart disease.