From controlled trials to clinical practice: monitoring transmyocardial revascularization use and outcomes.
OBJECTIVE
We sought to examine trends in the use and outcomes of transmyocardial revascularization (TMR) in community practice. We also identified important risk factors for TMR and compared outcomes of TMR combined with coronary artery bypass graft surgery (TMR + CABG) versus bypass alone in patients receiving incomplete revascularization.


BACKGROUND
Although it is approved for use as a stand-alone procedure, there are limited data on the outcomes of (TMR + CABG).


METHODS
We identified 3,717 patients receiving TMR at 173 U.S. hospitals participating in the Society of Thoracic Surgeons (STS) National Cardiac Database. Baseline characteristics and outcomes in these patients were compared with those from six published randomized TMR trials. Multivariable logistic regression was used to identify clinical risk factors for mortality with TMR. Risk-adjusted mortality was also compared for TMR + CABG relative to CABG only in patients not amenable to complete traditional revascularization.


RESULTS
Between January 1998 and December 2001, the number of STS hospitals performing TMR and total procedural counts increased markedly, driven predominately by more TMR + CABG cases. Overall mortality rates for TMR-alone and TMR + CABG were 6.4% and 4.2%, respectively. Operative risks were significantly higher in those patients with recent myocardial infarction, unstable angina, and depressed ventricular function. Among patients receiving incomplete revascularization, TMR + CABG was not associated with decreased mortality risk compared with CABG alone, adjusted odds ratio 1.11 (95% confidence interval 0.74 to 1.67).


CONCLUSIONS
The use of TMR, and in particular, TMR + CABG, is expanding in community practice. Although procedural risks are high, there is room for optimization through improved patient selection and timing of the procedure. Further studies of TMR + CABG are needed given its growing use and unclear benefits.
Peterson
Eric D
ED
Duke Clinical Research Institute, Durham, North Carolina 27710, USA. peter016@mc.duke.edu
Kaul
Padma
P
Kaczmarek
Ronald G
RG
Hammill
Bradley G
BG
Armstrong
Paul W
PW
Bridges
Charles R
CR
Ferguson
T Bruce
TB
D000368:Aged; D018849:Controlled Clinical Trials as Topic; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D053685:Laser Therapy; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009204:Myocardial Revascularization / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians'; D012042:Registries; D012307:Risk Factors; D016896:Treatment Outcome