title: Transmyocardial laser revascularisation combined with coronary artery bypass grafting without cardiopulmonary bypass.
abstract: OBJECTIVE
  To achieve complete myocardial revascularisation in patients with diffuse coronary artery disease, patients with inordinately high risk of cardiopulmonary bypass (CPB) like severe systemic disease or diffuse atherosclerosis of the aorta.
  
  
  METHODS
  We have adopted the technique of combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR) using 1000 W CO2 laser machine. TMLR is done to areas supplied by ungraftable arteries, while CABG without cardiopulmonary bypass is done to the left anterior descending artery (LAD) and/or right coronary artery (RCA). TMLR + CABG on beating heart without CPB has been performed on 56 patients. Age ranged from 37 to 81 years with a mean of 56.17. Four patients were in renal failure, two were redo CABG. Preoperatively 39.28% patients had angina class III and 10.71% had angina class IV. Four patients were on preoperative IABP support.
  
  
  RESULTS
  The mean number of grafts was 1.09. Internal thoracic artery (ITA) was used in 96.4% of the patients. Five patients showed elevation of CPK-MB, while three patients had an increase in Troponin T. Mortality was 1.8% (one patient died of intractable ventricular arrhythmia). The mean follow-up is 9.2 months. Myocardial perfusion scanning showed a stepwise improvement in reversible ischemia increasing from 52% at baseline to 91% at 12 months; 90.9% of the patients were angina free at 12 months. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 min at baseline to 9.4 min at 12 months. Metabolic equivalents (METs) increased from 4.5 at baseline to 9.4 at 12 months. The average 44% Karnofsky score preoperative also increased to 86% at 12 months.
  
  
  CONCLUSIONS
  Our results indicate that the technique is surgically feasible and safe, with excellent short term results.
authors.affiliation: Escorts Heart Institute and Research Centre, New Delhi, India.
authors.forename: N
authors.initials: N
authors.lastname: Trehan
authors.forename: M
authors.initials: M
authors.lastname: Mishra
authors.forename: R
authors.initials: R
authors.lastname: Bapna
authors.forename: A
authors.initials: A
authors.lastname: Mishra
authors.forename: P
authors.initials: P
authors.lastname: Maheshwari
authors.forename: A
authors.initials: A
authors.lastname: Karlekar
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002315:Cardiopulmonary Bypass; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000295:instrumentation / Q000379:methods*; D003327:Coronary Disease / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D053685:Laser Therapy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome