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Synergy of old and new technology results in successful revascularization of the anterior myocardium with relief of angina in the absence of suitable targets.

BACKGROUND
Diffuse and distal left anterior descending (LAD) coronary disease that is refractory to conventional surgical and/or percutaneous revascularization represents a clinical and economic dilemma. Transmyocardial laser revascularization (TMLR) has improved angina without clear measurable improvement of myocardial perfusion. This study was undertaken to determine if combining a Vineberg implant with TMLR of the LAD distribution enhances myocardial perfusion and relieves symptoms.


METHODS
Twenty-one patients with an obliterated LAD and a viable anterior wall underwent off-pump coronary artery bypass grafting (OPCAB) (2.6 grafts/patient). Eight were studied with preoperative, postoperative-early (4-9 days), and postoperative-late (3-5 months) stress and rest nuclear imaging. In all but 3 cases, the Vineberg implant was modified such that the distal end of the conduit, as it emerged from the muscular tunnel, was anastomosed to any patent LAD segment. The anterior wall, to the left of the LAD, was also instrumented with a Holmium yttriumaluminum- garnet laser (8-16 sites).


RESULTS
There has been 100% follow-up with durations ranging from 6 to 36 months. There were no deaths. All patients had complete relief of their angina. Serial perfusion scans demonstrated a 2-phase improvement in perfusion. Three of the patients underwent angiography of the implant at 6 to 9 months; angiography in each case demonstrated a patent robust conduit. The 1 patient studied at 24 months demonstrated several sites of a myocardial "blush" consistent with neovascularization.


CONCLUSIONS
Although some of the benefits of TMLR/Vineberg may be a consequence of collateral blood flow from other revascularized regions, we believe there to be a synergistic effect on perfusion and angina relief by these combined procedures which may be related to angiogenesis.