Refractory angina despite patent coronary artery bypass grafts: treatment with transmyocardial laser revascularization and scintigraphic evidence of improved myocardial perfusion

Progression of coronary artery disease that causes recurrent angina in patients who have already undergone coronary artery bypass grafting (CABG) is a challenge to cardiac surgeons. The presence of myocardial ischemia that is not due to bypass grafts occlusion, but to the quality of the coronary vessels characterized by diffuse atherosclerotic peripheral disease, makes the situation even more difficult, since it is not possible to perform myocardial revascularization either by percutaneous transluminal angioplasty (PTCA) or by means of new grafts. We report the case of a patient who, 4 years after triple CABG, developed refractory angina despite patency of bypass grafts (to left anterior descending artery, obtuse marginal branch and posterior descending) and maximally tolerated conventional medical treatment. Native coronary arteries were occluded. Because of the exiguous caliber of the distal portion of epicardial vessels and poor run-off, a redo CABG was judged to be unfeasible. Transmyocardial laser revascularization (TMLR) was performed through left anterior thoracotomy, minimizing the risk of damage to the grafts. Clinical improvement (from CCS class IV to 0) and scintiscan showing improved myocardial perfusion to the laser-treated regions confirm the effectiveness of TMLR in otherwise inoperable coronary artery disease.