Images in cardiovascular medicine. Improvement of myocardial perfusion after transmyocardial laser revascularization and coronary artery bypass graft surgery.

A69-year-old man with severe angina had severe 3-vessel disease by coronary angiography. At the time of coronary revascularization, he had left internal mammary artery implantation to the left anterior descending artery, a vein graft to the diagonal branch, and a vein graft to the marginal branch of the left circumflex artery. Transmyocardial laser revascularization was performed in the territory of the right coronary artery (because of poor distal runoff) with a xenon chloride excimer laser (under an investigational device exemption sponsored by United States Surgical Corp). The postoperative course was uneventful. The patient experienced improvement of symptoms. The patient had an exercise treadmill test by the Bruce protocol before and '3 months after surgery. Before surgery, he developed angina during exercise with STsegment depression at 75% of maximum predicted heart rate. After surgery, he exercised to 87% of maximum predicted heart rate with no angina or ST-segment depression. Before surgery, exercise single photon emission CT (SPECT) Tc-sestamibi myocardial images revealed extensive reversible perfusion defects consistent with 3-vessel ischemia. After surgery, the exercise SPECT perfusion images were almost normal (Figure). The improvement in the perfusion pattern during exercise was equally remarkable in the vascular area treated with laser and the vascular territories treated with bypass surgery.