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Objective: The aim of this study is to evaluate the short and mid-term efficacy of the Transmyocardial High Power CO2 Laser Revascularisation (TMLR) as a last resource method for end-stage coronary disease patients. Method and patients: The High Power CO2 Laser 800 W Heart Laser (PLC Medical Systems) was used since February 1994 to treat 268 patients. In 52% of the cases (140) the indication for TMLR treatment was virtual inoperability by the classical bypass revascularisation. In the other 128 patients (48%), where only an incomplete revascularisation was expected, the TMLR was combined with a feasible bypass revascularisation (CABG). Of all patients, 71% were operated on 1‐5 times before and or treated by several percutaneous transluminal coronary angioplasty (PTCA). All patients were sufferers of angina pectoris and most were classified Canadian Cardiac Society (CCS) 3-4, despite the maximal medical treatment. The ejection fraction was normal in 13% of patients only, and in 47% of them it was below 40% (10‐68%). Results: The operation itself was generally well tolerated. We lost only one patient at the table. The hospital survival was 89.2%; 88.2% in the combined group and 90.3% in the TMLR only group. After the routine follow up screening 3, 6 and 12 months postoperatively (262 patients—131 TMLR and 131 TMRL:CABG), 40% of the TMLR patients upgraded into the functional class CCS 0-1; the combined group of patients scored up even in 84%. All considering their quality of life to be ‘better than years ago’. The ergometry stress test, impossible for most of them before, became feasible and better in 80% of the patients. In the follow up period of the combined group, another 6 (4.7%), and in the TMLR only group, 12 (9.4%) patients died. Conclusion: The short and middle term results of this—until now the largest single institution series of TMLR treated patients—were that patients almost without execption were refused for any kind of surgery by several other centres; this shows an acceptable survival rate and a surprising level of pain relief, increased activity and better quality of life then ever expected. In our experience, TMLR is a suitable method for treatment of end stage coronary disease, if all standard measures, medical therapy, PTCA and redo coronary revascularisation possibilities are exhausted. The favourable results imply the question as to whether this method will become an alternative for a second bypass operation in the future. The TMLR as an alternative for heart transplant is already a reality for some of our patients. © 1997 Elsevier Science B.V.

The authors began ventricular assist pumping as treatment for postcardiotomy cardiogenic shock in November 1988 with a new automated pulsatile support system, the ABIOMED BVS 5000 Bi-Ventricular Support System. Five patients (0.6% of total cardiac surgery patients) have been placed on support, four after coronary artery bypass grafting, and one after bypass grafting and mitral valve repair. All patients were refractory to pharmacologic and intraaortic balloon pump therapy. Three patients had left ventricular support and two had biventricular support. Four patients were successfully weaned, and three are long-term survivors. Duration of support ranged from 39 to 118 hours (mean, 89.4 hours). Resternotomy was performed in four patients: twice for hemostasis, once for tamponade, and once for inadequate left ventricular drainage. Three patients, two nonsurvivors and one survivor, had perioperative myocardial infarctions. No device related thromboembolic complications, hemolysis, or infection were experienced. Follow-up at more than 1 year demonstrated that all patients are in NYHA Class 1. Ventricular assist pumping with the ABIOMED BVS 5000 Bi-Ventricular Support System is an effective treatment for postcardiotomy cardiogenic shock.

The symptomatology of a typical acute descending thoracic aorta dissection was imitated by profuse haemorrhage caused by a benign tumour composed almost exclusively of Wagner-Meissner like tactile corpuscles and fatty tissue. The tumour caused extensive destruction of the bodies of the fifth and sixth thoracic vertebrae at the level of the vertebro-costal articulation. Emergency cross clamping of the descending aorta and haemostasis of the bleeding from osteal defects by tamponade with bone polymethyl methacrylate appeared the only way to control the life threatening haemorrhage. It seems that an intrathoracic tactile neurofibroma with a similar case history has not been reported till now.

Between 1975 en 1988, 16 patients underwent pulmonary embolectomy because of massive pulmonary embolism. Three of these patients, in whom shock and cardiac arrest had occurred prior to operation, died. The role of surgery in the treatment of massive pulmonary embolism is a topical issue, also in view of the rise of thrombolytic therapy and its acceptable results. For patients whose haemodynamic condition deteriorates in spite of thrombolytic treatment and for patients in whom thrombolytic therapy is contraindicated, pulmonary embolectomy remains an effective form of treatment.

Comparison was made between the morphologic condition of the left anterior descending artery and four arterial conduits: the internal mammary, right gastroepiploic, inferior epigastric, and radial arteries, harvested from 17 patients (aged 15 to 85 years, mean 64 years) who had died of nonvascular diseases. Proximal, mid, and distal segments were examined microscopically. The internal mammary artery was elastic, but the others were muscular. In all four conduits, atherosclerosis was absent to mild, the internal elastic lamina showed only minimal defects, and the vasa vasorum were confined to the adventitia. In all cases the left anterior descending artery showed mild to severe atherosclerosis and substantial defects in the internal elastic lamina with penetration of the vasa vasorum into the media and intima. Comparison of the mean distance (+/- standard deviation) from the lumen to the outermost portion of the media for the left anterior descending artery (320 +/- 63 microns) with the four conduits gave comparable values for the internal mammary artery (350 +/- 92 microns); p = not significant) and the right gastroepiploic artery (291 +/- 109 microns; p = not significant), versus 529 +/- 52 microns; p less than 0.002) for the radial artery and 249 microns (+/- 87 microns) (p less than 0.04) for the inferior epigastric artery (Kruskal-Wallis and Mann-Whitney U tests). The relatively scanty presence of smooth muscle cells in the thin-walled media of the internal mammary artery combined with a well-formed internal elastic lamina, even at advanced age, may be an important cause for its low susceptibility to atherosclerosis and a major determinant in its superior long-term patency as a coronary artery bypass graft. This finding emphasizes the justification of continued use of the ideally matching internal mammary artery, either as in situ or free graft, in coronary artery bypass grafting. In contrast to the thick-walled radial artery, which may be relatively prone to ischemia, an acceptable long-term patency of the inferior epigastric artery and right gastroepiploic artery, if harvested as pedicled grafts, is anticipated.