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Ann Thorac Surg 2000;70:498-503
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Transmyocardial laser revascularization with excimer laser: clinical results at 1 year

^a Department of Cardiothoracic Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
^b Cardiology, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
^c Nuclear Cardiology, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA

Address reprint requests to Dr Rosengart, Evanston Northwestern Healthcare, 2650 Ridge Ave, Burch 100, Evanston, IL 60201
e-mail: trosengant{at}enh.org

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Transmyocardial laser revascularization, a new strategy for the treatment of diffuse ischemic heart disease, uses laser technology for the theoretical purpose of forming transmyocardial channels in the heart to increase perfusion to ischemic zones. This report summarizes our initial clinical experience with the procedure.

Methods. Excimer transmyocardial laser revascularization was performed in a reversibly ischemic region of the heart in 15 patients. Ischemia and myocardial viability were evaluated by assessment of symptoms and of results of radionuclide single photon emission computed tomography imaging, exercise tolerance testing, and 24-hour Holter monitoring.

Results. No adverse events occurred as a result of the laser revascularization, although 1 patient with preoperative ventricular arrhythmias died 48 hours postoperatively as a result of refractory ventricular tachycardia. Angina class decreased significantly from base line values in patients who had undergone the procedure (mean Canadian Cardiovascular Association angina class, 3.5 ± 0.5 at base line, 1.6 ± 0.6 at 1 month, 1.5 ± 0.8 at 3 months, 1.9 ± 0.9 at 6 months, 1.8 ± 0.8 at 12 months; p < 0.002), and nitroglycerin requirements were similarly decreased in patients who had undergone laser revascularization (mean g/wk of sublingual nitroglycerin, 19 ± 4 at baseline, 5 ±3 at 1 month, 4 ± 2 at 3 months, 4 ± 2 at 6 months, 2 ± 1 at 12 months; p <0.02). Exercise tolerance testing demonstrated increase in exercise duration compared with base line values (mean minutes, 7.4 ± 3.1 at base line, 8.0 ± 3.9 at 1 month, 8.5 ± 4.4 at 3 months, and 9.0 ± 3.9 at 12 months; p >0.05); those increases were not large enough to be statistically significant, however.

Conclusions. Our data are consistent with the concept that excimer transmyocardial laser revascularization in individuals with significant ischemic heart disease appears to be well tolerated, can be performed safely, and may lead to a reduction in ischemic symptomatology.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Conventional interventional treatment of coronary artery disease has long consisted of percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). Although these therapies have produced enormous benefits in thousands of patients over the past three decades, there exists a large number of individuals with significant coronary artery disease—many of whom have previously undergone multiple PTCA procedures, multiple CABG procedures, or both—in whom standard therapies cannot be used because of the diffuse nature of their disease. Transmyocardial laser revascularization (TMR) is a technique whereby transmural channels are created in regions of ischemic myocardium for the purpose of providing perfusion of this tissue with oxygenated blood derived directly from the left ventricle. TMR may be ideally suited for treating patients in whom adequate myocardial perfusion can no longer be provided by the native epicardial coronary vasculature.

Early investigators recognized the significance of myocardial sinusoids and the potential contribution of these intramural lacunae to the perfusion of the myocardium. Sen and colleagues in 1965 proposed the use of so-called transmural acupuncture in the canine model for the purpose of bathing ischemic cells with oxygenated blood derived directly from the lumen of the left ventricle, based on reptilian anatomy in which similar myocardial sinusoids appeared to play an important role in myocardial perfusion [1]. In early studies of transmyocardial acupuncture, a procedure used clinically in the setting of stable angina and for acute infarction, there was evidence of improved myocardial blood flow and improved clinical outcomes . However, no clinical trials were conducted. Mirhoseini and colleagues in 1982 reported the use of a 80-W CO₂ laser to make transventricular channels on the beating heart [2], a milestone that culminated in the recent Food and Drug Administration approval of the CO₂ and holmium:yttrium-aluminum garnet (YAG) lasers for the purpose of performing TMR.

Three primary laser systems have been evaluated as TMR devices: the CO₂ and the holmium:YAG lasers, which operate in the infrared spectrum and vaporize tissue by superheating water molecules in the target tissues, and the excimer laser, which operates in the ultraviolet range of the spectrum and is considered to be a cold laser because it photoablates tissue by direct superexcitation of molecular bonds. Theoretically, differences between the high and low laser energy tissue ablation mechanisms may translate into different therapeutic efficacies [3]. Herein, we report the outcome of 15 patients who underwent TMR as sole therapy utilizing the excimer laser (AccuLase, San Diego, CA and Baxter Healthcare Corporation, Irvine, CA). The significant reduction in angina class produced by excimer laser treatment suggests that this device may represent an alternative means of inducing TMR by a low-energy mechanism.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients were enrolled after providing informed consent in an Institutional Review Board approved study (approved August 19, 1996, with renewal every 6 months. Final termination was January 20, 1999). Enrollment was based on (1) the presence of coronary artery disease not amenable to CABG or PTCA due to the diffuse or severe nature of the coronary artery disease documented by a recent coronary angiogram and (2) the presence of areas of reversible myocardial ischemia demonstrated by an adenosine thallium single photon emission computed tomography scan. Additional inclusion criteria were: Canadian Cardiovascular Society Class III or IV angina refractory to medical therapy. Angina class and oral nitroglycerin use were determined by use of a questionnaire given to each of the patients preoperatively and at postoperative timepoints. Exclusion criteria included history of a cerebral vascular accident or myocardial infarction within 6 weeks of the procedure, current treatment with Coumadin, evidence of infection, preoperative congestive heart failure, severe chronic obstructive pulmonary disease, unstable angina requiring intravenous nitroglycerin, or hospitalization within 2 weeks of the procedure.

Between October 14, 1996, and April 25, 1998, 20 patients with stable angina refractory to optimal medical therapy, and coronary artery disease not amenable to conventional interventions, as defined above, were screened for possible inclusion into the study. Of the 20 individuals initially screened, 15 met the study inclusion criteria and underwent TMR. Two patients who reported angina at rest but required no intravenous nitroglycerin therapy did not undergo stress testing at base line for safety reasons. The average age of the study patients was 64 years; 11 were male and 4 female (Table 1). The mean ejection fraction was 38%. The most prevalent patient characteristics were prior CABG (in 80%), prior PCA (in 53%), and hypertension (in 64%). There were two deaths and one patient refused further follow-up. The remaining 12 patients in the study have undergone follow-up for 540 ± 180 days (range, 210 to 830 days).

Exercise tolerance testing was performed preoperatively and at 1, 3, 6, and 12 months postoperatively according to a modified Bruce protocol [4]. Each stage of the Bruce protocol was divided into half stages to produce heart rate increments of approximately 10 beats/min. The protocol consists of 2-minute stages, beginning with stage 0 at 1.7 mph and 0% grade and gradually increasing in a stepwise fashion to stage 5 at 5.0 mph at an 18% grade. Exercise duration and ST segment/heart rate slope, ascertained from peak exercise regression of ST depression expressed as a positive value referenced to heart rate, were computed using conventional methodology [4].

A 24-hour Holter monitor reading was obtained at base line, immediately after the operation, and at 1, 3, 6, and 12 months. Using methodology previously established in our laboratory [5], we performed supraventricular rhythm evaluation that included quantification of the mean number of atrial premature complexes per hour, peak density of atrial premature complexes per hour, and qualitative tabulation of atrial couplets, paroxysmal atrial tachycardia, and atrial flutter or atrial fibrillation. Ventricular rhythm evaluation included quantification of mean number of ventricular premature complexes per hour, peak density of ventricular premature complexes per hour, and qualitative tabulation of ventricular complexity.

Operative procedure
Patients were prepared for anesthesia and surgery in the standard fashion. Double lumen endotracheal intubation was employed, and an arterial line and a pulmonary artery catheter were placed. A transesophageal echocardiography probe (Hewlett Packard, Andover MA) was used to assess myocardial wall thickness and subsequent determination of transmural penetration of the TMR channels. A left anterolateral thoracotomy was performed, and pericardiotomy was created under direct visualization to allow adequate exposure of the heart in the region to receive TMR. Just prior to the laser procedure, each patient empirically received a bolus of lidocaine and was started on a continuous infusion of 1 mg/min that was maintained through the first 24 postoperative hours for arrhythmia prophylaxis. In addition, each patient received a heparin bolus of 100 U/kg before undergoing TMR.

We used an excimer laser (AccuLase, Inc, San Diego, CA) with a 600-µm fiberoptic system at energy settings of 9 mJ and 240 Hz and a fiberoptic advancement rate of 1.55 cm/s to produce channels on the beating heart. The excimer fiber advancement depth was adjusted to assure full thickness penetration of the myocardium based upon left ventricular thickness at end systole. Advancement depth was increased by 2-mm increments if penetration was not detected by transesophageal echocardiogram. From 24 to 60 channels, each 1 mm in diameter, were placed in the left ventricular free wall as exposed by the left thoracotomy. Full-thickness penetration of the myocardium was verified by bubble formation in the left ventricular cavity evident on transesophageal echocardiography. The average number of TMR channels placed was 41 ± 16 (range, 24 to 61) with a confirmation of transmural penetration by transesophageal echocardiography in 73% of attempts. Hemostasis typically occurred spontaneously, although in a few patients, channels required a brief period of manual compression or suturing with a 6-0 polypropylene suture.

After the TMR procedure, thoracostomy tubes were placed, the chest was closed in the standard fashion, and the patients were monitored in the intensive care unit for 24 hours with evaluation of serial creatinine phosphokinase of the muscle band (CPK-MB) levels and electrocardiograms. Hospital discharge was allowed when clinically appropriate.

Statistical analysis and data collection
Data were collected at base line, perioperatively, and at the designated timepoints of 1, 3, 6, and 12 months after the operation. All statistical analyses were performed using either the paired ttest or analysis of variance employing Bonferroni multivariate analysis. All figures are presented as mean ± standard deviation.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Morbidity and mortality
There were no intraoperative deaths or complications, including sustained ventricular arrhythmias, despite the fact that the excimer device does not incorporate computer synchronization of lasing and that patients therefore experienced a series of premature ventricular beats that terminated spontaneously accompanying laser fiber penetration of the myocardium. One death (6.6%) occurred in the 30-day postoperative period. This death was the result of intractable ventricular tachycardia occurring 48 hours after an uncomplicated TMR procedure. Although this patient did not have a previous history of ventricular arrhythmias, ventricular ectopy did occur during preoperative stress testing. One additional death occurred at 4 months after the operation, yielding a 1-year mortality of 13.3%. That second death occurred in a patient who had experienced a myocardial infarction 8 hours postoperatively that resulted in mitral regurgitation. The patient subsequently died of complications related to the prosthetic valve. There were no other postoperative complications in any of the other TMR patients and no episodes of postoperative tamponade The average length of hospital stay after the procedure was 6.5 ± 2.2 days (range, 4 to 12 days). There was a transient increase in CPK-MB over the reference value of 0.0 to 3.0 mg/dL during the early postoperative period (peak CPK-MB level, 26 ± 22 mg/dL at 8 ± 6 hours postoperatively). Despite the transient and self-limited increase in CPK-MB, no new ST changes or Q waves were apparent on electrocardiograms obtained during the acute postoperative period except in the 1 patient, described above, who experienced a postoperative myocardial infarction. Nor were there any such electrocardiographic changes at 1, 3, 6, or 12 months after the operation. To date, there have been no additional deaths or major complications in the 12 patients available for follow-up. In addition, there has also been no increase over baseline values in supraventricular or ventricular arrhythmias as assessed by 24-hour Holter monitoring at 1, 3, 6, and 12 month follow-up.

Angina class
Assessment of angina status as determined by the Canadian Cardiovascular Society classification of angina showed a consistent improvement at 1, 3, 6, and 12 months compared with preoperative values (Fig 1). The mean angina class was 3.5 ± 0.5 at base line, 1.6 ± 0.6 (p < 0.0001) at 1 month, 1.5 ± 0.8 (p < 0.0001) at 3 months, 1.9 ± 0.9 (p < 0.0002) at 6 months, and 1.8 ± 0.8 (p < 0.002) at 12 months. These results correlated well with weekly baseline versus postoperative sublingual nitroglycerin use (Fig 2). Weekly sublingual nitroglycerin usage of tablets was 19.0 ± 4.2 at baseline, 5.2 ± 2.6 (p < 0.004) at 1 month, 3.8 ±1.7 (p < 0.002) at 3 months, 3.8 ± 1.5 (p < 0.004 vs base line) at 6 months, and 1.7 ± 0.5 (p < 0.02 vs baseline) at 12 months. Other antianginal medication dosages did not substantially change during this time.

View larger version (12K): [in this window] [in a new window]   Fig 1. Angina class before TMR and at 1 month, 3 months, 6 months, and 12 months following TMR. Canadian Cardiovascular Angina classification based upon direct questioning of patients at the timepoints indicated. The data are represented as mean ± standard deviation with the base line represented as the solid square and 1 month, 3 months, 6 months, and 12 months following TMR represented as open squares. * p value comparing postoperational with base line timepoints (TMR = transmyocardial laser revascularization.)

View larger version (13K): [in this window] [in a new window]   Fig 2. Sublingual nitroglycerin intake per week before therapy and at 1 month, 3 months, 6 months, and 12 months following TMR. The data are represented as mean ± standard deviation with the base line represented as the solid square and 1 month, 3 months, 6 months, and 12 months following TMR represented as open squares. * p value comparing postoperational with base line timepoints. (TMR = transmyocardial laser revascularization.)

View larger version (13K): [in this window] [in a new window]   Fig 3. Exercise tolerance testing–exercise duration before therapy and at 1 month, 3 months, 6 months, and 12 months following TMR. The data are represented as mean ± standard deviation with the base line represented as the solid square and I month, 3 months, 6 months, and 12 months following TMR represented as open squares. * p value comparing postoperational with base line timepoints. (TMR = transmyocardial laser revascularization.)

View larger version (12K): [in this window] [in a new window]   Fig 4. Exercise tolerance testing ST/HR slope before therapy and at 1 month, 3 months, 6 months, and 12 months following TMR. ST/HR slope was determined from peak exercise regression of ST depression expressed as a positive value referenced to heart rate. The data are represented as means ± standard deviation with the base line represented as the solid square and 1 month, 3 months, 6 months, and 12 months following TMR represented as open squares. * p value comparing postoperational with base line timepoints. (ST/HR = ST segment/heart rate slope; TMR = transmyocardial laser revascularization.)

View larger version (11K): [in this window] [in a new window]   Fig 5. Myocardial viability before therapy and at 3 months, 6 months, and 12 months following TMR. Myocardial viability was assessed by 24-hour redistribution thallium nuclear medicine scan at the timepoints indicated. The data are represented as means ± standard deviation with the base line represented as the solid square and 1 month, 3 months, 6 months, and 12 months following TMR represented as open squares. * p value comparing postoperational with base line timepoints. (TMR = transmyocardial laser revascularization.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

The current study clearly demonstrates improvement both in terms of nitroglycerin intake and in angina classification that approximates results reported in previous studies. Although our study did not demonstrate either an increase in the amount of viable myocardium by thallium scanning or an improvement in exercise tolerance testing, that outcome may be due to the small sample size of this phase I study and the lack of placebo controls. The relative insensitivity of the parameters assessed in this study, as opposed to more sensitive indicators such as PET scans, may have also contributed to the outcome. Nevertheless, this trial illustrates the technical feasibility of performing TMR with an excimer laser and provides evidence that TMR utilizing the excimer laser in persons with significant ischemic heart disease is well tolerated and can be performed safely. Specifically, excimer TMR resulted in only transient and self-limited increases in the CPK-MB and no electrocardiographic changes in the early postoperative period.

Although the exact mechanism by which TMR produces benefits remains unclear, several alternative theories have been suggested. Explanations of the TMR effect include the potential roles of patent laser channels [6]; the development of channel derivatives, whereby the thrombosed primary channel creates a framework for neovascularization and recanalization [3, 18, 19]; laser-mediated injury stimulating angiogenesis [8, 18–22] and cardiac denervation [23, 24]; and placebo effects [23, 24]. As more information is gained with continuing animal studies and the results of ongoing clinical trials, the single or possibly multiple mechanisms by which TMR exerts its effects may become more apparent.

A final point is that there may exist a theoretical advantage of using the excimer laser over the other available lasers for TMR, which include the CO₂ and the holmium:YAG. The excimer, like the holmium:YAG, utilizes a fiberoptic that directs laser energy to the specific region of TMR. This may be of particular benefit in minimally invasive delivery strategies. Perhaps more importantly, the so-called cold, low-energy excimer laser, which operates in the ultraviolet spectrum, may produce less potentially detrimental thermal and acoustic injury to myocardial tissues than the CO₂ and holmium:YAG lasers [4, 25]. Given our poor understanding of the mechanisms underlying TMR, however, large scale phase II and III trials are necessary to determine whether or not these theoretical benefits of the excimer laser translates into a greater efficacy than other TMR lasers. [15, 16, 17]

	Footnotes

 
The authors acknowledge Baxter Healthcare Corp, Inc, and AccuLase, Inc, whose generosity partially supported this study.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): O. Wayne Isom Todd K. Rosengart Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, L. Y. Articles by Rosengart, T. K. Search for Related Content PubMed PubMed Citation Articles by Lee, L. Y. Articles by Rosengart, T. K.