الفهرس 
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Abstract
Transmyocardial laser revascularization (TMLR) is an emerging surgical therapy for the treatment of ischemic heart disease not amenable to conventional percutaneous or surgical revascularization techniques. Although an analogous network of myocardial sinusoids exists in humans, its role in perfusion remains poorly defined. Despite the success of current medical and surgical management of ischemic heart disease, a growing number of patients have diffuse obstructive coronary artery disease that is not amenable to coronary-artery bypass grafting or catheter-based interventions. The failure to revascularize even a single ischemic coronary artery due to poor graftability is associated with a decrease in both survival and freedom from angina in these patients. This problem has stimulated interest in developing alternative therapeutic approaches. Since the early 1990s, carbon dioxide laser systems have been used to perform TMLR in humans, with excellent results. AIM OF THE WORK: To study the intermediate-term (2 years) effectiveness and complications of Transmyocardial Laser Revascularization (TMLR) in patients with end stage coronary artery disease not candidate to other methods of revascularization using CO2 laser as a sole maneuver.Patients and Methods: This study is a retrospective clinical study performed in the National Heart Institute to find out the intermediate-term effectiveness and complications of Transmyocardial Laser Revascularization (TMLR) for patients had end-stage coronary artery disease not candidate for PCI or CABG in the period from January 2001 to December 2002. Fifty patients were included in the study.Fifty patients with the following criteria were included in the study:1)Canadian Cardiovascular angina Class (CCS) III or IV.2)Have evidence of reversible ischemia (based on stress thallium perfusion scanning and dobutamine stress echocardiography).3)Diffuse CAD not amenable for CABG or PCI (according to the results of coronary angiography). The decision to do TMLR was based on opinion of a weekly committee consisting of seven doctors:A coronary angiographer. -Two cardiologists- And four surgeons 4) No active chronic obstructive pulmonary disease.Exclusion criteria: Serum albumin level of 3.9 – 6 g/dl or evidence of significant liver impairment, Severe renal impairment, Pregnancy, Less than 18 years of age, Inability to comprehend or follow instructions and Inability to provide informed consent. All patients included in the study were subjected pre-operatively to the following investigations:1.Complete history taking and full general and local examination of the heart.2.Routine laboratory investigations including: kidney function test, liver funstion test, blood sugar and total cholesterol.3.Resting 12 leads ECG.4.Chest X-Ray.5.Transthoracic Echocardiography.6.Coronary Angiography.7.Dobutamine Stress Echocardiography.8.Stress Thallium 201 (Th-201)Sestamibi Scintigraphy Radionuclide Study.PRE OPERATIVE PREPARATION: Pre-operative education for the patient and family was done as for any routine cardiac surgery teaching plan. Continuous monitoring of vital signs, oxygen saturation, cardiac rhythm, and hourly intake and output were done routinely. Regions of the left ventricle to be treated by TMLR were identified based on ischemic viable areas noted on the preoperative angiography, thallium and dobutamine stress echocardiographic images. A left ventricular map of 12 segments was made. Of these 12 segments possible reperfusible areas to be lased were identified. ANESTHETIC MANAGEMENT: Monitoring of ABP, CVP, PWP and TEE. The eyes of the surgical team were shielded with special glasses. Induction and maintenance of both; general anesthesia and special considerations. Follow-up:Follow-up for patients was done up to 24 months.Patients were followed-up every week for 3 months and every month for the first year and then every 6 months using clinical examination, ECG and echocardiography.Gradual withdrawal of the medical treatment started during the first three months post-operatively.Stress thallium SPECT was done after 6 months and at the end of the follow-up period.Coronary angiogram was done for some patients.