Transmyocardial laser revascularization: Results of a multicenter trial with transmyocardial laser revascularization used as sole therapy for end-stage coronary artery disease

Horvath, Keith A.; Cohn, Lawrence H.; Cooley, Denton A.; Crew, John R.; Frazier, O. H.; Griffith, Bartley P.; Kadipaşaoǧlu, Kâmuran A.; Lansing, Allan M.; Mannting, Finn; March, Robert; Mirhoseini, Mahmood; Smith, Craig R.

doi:10.1016/s0022-5223(97)70221-6

Cited by 291 publications

(120 citation statements)

References 23 publications

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“…Increased myocardial perfusion, directly through the patent channels or indirectly via laser-induced neovascularization, has been the main proposed mechanism of angina relief. Angina relief has been a consistent finding of most clinical studies 3,5,12,20,21 regardless of the kind of laser used, CO 2 or Ho:YAG. However, increased perfusion, channel patency, and neovascularization have all been very variable findings.…”

Section: Discussionsupporting

confidence: 54%

“…Dynamic images were acquired according to the following protocol: After positioning of the patient, a 15-minute transmission scan was obtained to correct emission data for tissue attenuation. Ammonia dynamic image acquisition was performed for 30 minutes with varying frame duration (12 frames ϫ5, 6ϫ10, 3ϫ60, and 5ϫ300 seconds), starting with intravenous bolus injection of 20 mCi of NH 3 . Adenosine was used for stress testing.…”

Section: Positron Emission Tomographymentioning

confidence: 99%

“…1 Results of clinical studies continue to show that TMR is effective in relieving angina. [2][3][4][5] However, the exact mechanisms by which TMR exerts its effects and relieves angina are still controversial. The main proposed mechanisms include direct blood flow from the ventricular cavity to the ischemic myocardium through laser-created channels 2,6,7 and increased myocardial blood flow through neovascularization mediated by thermal or mechanical laser injury.…”

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confidence: 99%

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Cardiac Sympathetic Denervation After Transmyocardial Laser Revascularization

et al. 1999

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Background-Transmyocardial laser revascularization (TMR) has been shown to improve refractory angina not amenable to conventional coronary interventions. However, the mechanism of action remains controversial, because improved myocardial perfusion has not been consistently demonstrated. We hypothesized that TMR relieves angina by causing myocardial sympathetic denervation. Methods and Results-PET imaging of resting and stress myocardial perfusion with [13 N]ammonia (NH 3 ) and of sympathetic innervation with [11 C]hydroxyephedrine (HED) was performed before and after TMR in 8 patients with class IV angina ineligible for CABG or PTCA. A mean of 50Ϯ11 channels were created in the left ventricle (LV) with a holmium:YAG laser. A semiautomated program was used to determine NH 3 uptake and HED retention in the LV. Perfusion and innervation defects were defined as the percentage of LV with tracer uptake or retention Ͼ2 SD below normal mean values. All patients experienced improvement in their angina by 2.4Ϯ0.5 angina classes after surgery, Pϭ0.008. Sympathetic innervation defects exceeded resting perfusion defects in all patients before TMR (34.6Ϯ27.3% for HED versus 9.4Ϯ10.8% for NH 3 , Pϭ0.008). TMR did not significantly affect resting or stress myocardial perfusion but increased the extent of sympathetic denervation in 6 of 8 patients by 27.5Ϯ15.9%, Pϭ0.03. In the remaining 2 patients, both sympathetic denervation and stress perfusion defects decreased after surgery. Conclusions-TMR causes decreased myocardial HED uptake in most patients without significant change in resting or stress myocardial perfusion, suggesting that the improvement in angina may be at least in part due to sympathetic denervation. (Circulation. 1999;100:135-140.)

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Section: Discussionsupporting

confidence: 54%

Section: Positron Emission Tomographymentioning

confidence: 99%

mentioning

confidence: 99%

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Cardiac Sympathetic Denervation After Transmyocardial Laser Revascularization

et al. 1999

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“…[2][3][4][5][6][7] Although the mechanism for their putative benefit is controversial, these surgical and percutaneous laser procedures are widely believed to create clinical benefit through angiogenesis at the treatment sites. 8 A more direct approach for angiogenesis has relied on the delivery of genes encoded for angiogenic and vasculogenic growth factors into ischemic myocardium.…”

Section: Discussionmentioning

confidence: 99%

Percutaneous In Situ Coronary Venous Arterialization

et al. 2001

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Abstract-Diffuse coronary artery disease is frequently untreatable by coronary artery bypass or angioplasty. Many such "no-option" patients have been subjects for trials of angiogenesis using growth factor manipulation or laser injury. We think these novel revascularization strategies are limited by insufficient inflow to putative areas of new microvasculature and thus seek a more mechanical solution. We report the use of a catheter-based system for arterializing the adjacent anterior cardiac vein in a patient with chronic total occlusion of the left anterior descending coronary artery. A composite catheter system (phased-array ultrasound imaging system mounted on a catheter with extendable nitinol needle) was used to deliver an exchange-length intracoronary guidewire from the proximal left anterior descending coronary artery into the parallel anterior interventricular vein. Using standard angioplasty techniques, a fistula was then constructed from the proximal artery to the coronary vein using a self-expanding connector. The proximal vein was blocked with a novel self-expanding "blocker," thus precluding "steal" through the coronary sinus and forcing retroperfusion of the anterior wall. The procedure was completed without complication, and a follow-up angiogram at 3 months confirmed continued patency of the arteriovenous connection. This patient, who had severe angina before the procedure, has been asymptomatic for 12 months. Percutaneous in situ venous arterialization may be an effective therapy for diffuse, "untreatable" coronary disease by supplying a robust inflow of arterialized blood via retroperfusion to severely ischemic myocardium. W ith the combination of coronary artery bypass surgery and percutaneous coronary interventions, many patients with symptomatic coronary insufficiency can be effectively revascularized. Each year in the United States alone, nearly 1 million individuals undergo a percutaneous catheterbased intervention, with intracoronary stents used in most. An additional half million Americans have their coronary disease treated by aortocoronary surgical bypass.Despite the successful and widespread application of these revascularization procedures, a large number of patients are not good candidates for either angioplasty or surgery. These "no-option" patients frequently have diffuse coronary disease without a discrete target for angioplasty, stenting, or surgical bypass. It has been estimated that Ͼ100 000 patients each year may fall beneath the no-option rubric. 1 Many of these patients have recently been investigational subjects in trials focused on angiogenesis by vascular growth factor infusions or laser injury.We suspect that gene therapy and laser revascularization strategies may have a fundamental flaw: the creation of new blood vessels in ischemic myocardial tissue requires significant arterial inflow, which is not obviously enhanced by these techniques. Therefore, we sought a novel percutaneous revascularization approach with the potential to provide robust arterial inflow to a sev...

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“…With the CO 2 laser, 198 patients were randomized to TMR or initial medical therapy. 186 Holmium laser was also the subject of a randomized trial that enrolled 162 patients. 187 The results of these 2 trials are remarkably concordant with reduction of angina, improvement of functional status, and in select patients with ancillary nuclear imaging, improved perfusion.…”

Section: Topol and Serruysmentioning

confidence: 99%

Frontiers in Interventional Cardiology

1998

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I n more than 20 years since the first percutaneous coronary revascularization procedures, the field of interventional cardiology has proliferated beyond all expectations. Now more than 1 million procedures are performed worldwide each year. Stenting has revolutionized the field, which previously relied on balloon dilatation in the majority of patients. With Ϸ50% of patients now undergoing stent implantation, the groundwork is laid for further important advances. In this article, we discuss the 4 most important new advances in the field of interventional cardiology: platelet inhibition, prevention of restenosis, stent evolution, and angiogenesis.

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Transmyocardial laser revascularization: Results of a multicenter trial with transmyocardial laser revascularization used as sole therapy for end-stage coronary artery disease

Abstract: These combined results indicate that transmyocardial laser revascularization provides angina relief, decreases hospital admissions, and improves perfusion in patients with severe coronary artery disease.

Cited by 291 publications

References 23 publications

Cardiac Sympathetic Denervation After Transmyocardial Laser Revascularization

Cardiac Sympathetic Denervation After Transmyocardial Laser Revascularization

Percutaneous In Situ Coronary Venous Arterialization

Frontiers in Interventional Cardiology

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