Marked Rise in Transmyocardial Revascularization Seen in U.S.

The number of sites performing transmyocardial revascularization (TMR) in the US as well as the annual procedural volume increased dramatically between 1998 and 2001, new research shows.

These trends were largely due to a rise in combined cases of TMR/CABG — an off-label use of the technology.

The results also indicate that the operative risks of TMR, either alone or with CABG, are higher than those of more traditional revascularization procedures.

Given its unclear benefits, “our finding of the widespread use of TMR/CABG indicates a strong need for further studies of this procedure,” lead author Dr. Eric D. Peterson, from Duke University in Durham, North Carolina, and colleagues note in the November 5th issue of the Journal of the American College of Cardiology.

The new findings are based on a study of all patients who underwent TMR between 1998 and 2001 and were logged in a national thoracic surgery database. A total of 3717 patients were identified, including 661 who underwent TMR alone, 2475 treated with TMR/CABG, and 581 treated with TMR plus some other cardiac procedure.

The number of sites performing TMR increased from just 33 in 1998 to 131 in 2001, the authors note. This trend coincided with a rise in annual caseload from 59 procedures in the first half of 1998 to 572 in the second half of 2001.

TMR alone and TMR/CABG were associated with operative mortality rates of 6.4% and 4.2%, respectively–higher than the rates typically reported in the clinical trials of TMR. However, when the analysis was limited to patients without a recent MI, unstable angina, or a low ejection fraction, mortality for both procedures was nearly cut in half.

“To date, this study is the largest to evaluate TMR use and outcomes,” the investigators point out. “Although procedural risk are high, there is room for optimization through improved patient selection and timing of the procedure,” they add.

J Am Coll Cardiol 2003;42:1611-1616.