Transmyocardial Laser Revascularization Periprocedural Care

Updated: Sep 27, 2017
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Brett C Sheridan, MD, FACS  more...
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Periprocedural Care

Preprocedural Planning

Although clinical trials studying the effects of transmyocardial laser revascularization (TMLR) differ in protocol, eligible patients are provided information regarding the potential benefits and risks of this procedure. The workup before the procedure includes a complete history, physical examination, chest radiography, and echocardiography. Regions of the left ventricle to be treated by TMLR are identified on the basis of ischemic areas noted on the preoperative thallium scan image.

The surgical team does not have to wear special protective gowns during TMLR, but eyes must be shielded with special glasses.

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Equipment

A number of different laser technologies were developed while TMLR with the carbon dioxide laser was undergoing US Food and Drug Administration (FDA)-approved trials. The FDA has approved one carbon dioxide system and one holmium:yttrium-aluminum-garnet (YAG) system for this application. [6]  The experience described in this article focuses on the carbon dioxide laser. Other laser technologies are not coordinated with electrocardiography (ECG) and therefore may not protect against ventricular arrhythmias. Additionally, the other laser technologies do not produce high energy; therefore, they do not protect against perichannel burns and other forms of tissue destruction around the channels.

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Patient Preparation

Patients must be prepared and draped in the same manner that they would be for any open heart procedure. Most patients have a Swan-Ganz catheter and an arterial line placed for monitoring. In any reoperative case, external defibrillator pads are applied before the incision is made.

TMLR is performed with the patient under general anesthesia without the use of cardiopulmonary bypass (CPB) or anticoagulation. A double-lumen endotracheal tube is used to allow selective ventilation of the right lung, thus affording better exposure of the heart during the procedure. For monitoring, all patients need ECG, arterial pressure monitoring, Swan-Ganz catheterization, and transesophageal echocardiography (TEE).

TEE is used to confirm the accurate formation of transmural channels, which occur as a result of vaporization of the red blood cells within the myocardial wall. It is important to have resuscitative equipment in the operating room because touching of the myocardium and generation of the laser beam can sometimes trigger ventricular arrhythmias.

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Monitoring & Follow-up

TMLR is no longer an experimental procedure. Numerous trials have been completed, and long-term follow-up data are being collected. Regular follow-up care includes a history, a physical examination, and an evaluation of angina and quality of life. A series of tests, including echocardiography, thallium scanning, and exercise tolerance testing, are regularly performed. Whether TMLR has a significant impact on overall mortality in this patient population remains to be determined.

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