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Ann Thorac Surg 2005;80:1369-1370
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Invited commentary

Laser Center and Department of Intensive Care Medicine, Academic Medical Center University of AmsterdamMeibergdreef 9, NL-1105AZ, Amsterdam, the Netherlands

(Email: j.f.beek{at}amc.uva.nl; j.a.vandersloot{at}amc.uva.nl).

After 2 decades of research we can safely conclude that transmyocardial laser revascularization using a CO₂, Ho:YAG, or XeCl excimer laser is highly effective in relieving angina and improving quality of life in patients with severe refractory angina. Given the acceptable mortality rate and demonstrated efficacy, it is surprising that the use of transmyocardial laser revascularization is still limited. In part this can be explained by the initial elusive relationship between laser-mediated damage and anginal relief. After many hypotheses, including myocardial reperfusion through endothelialization of laser-induced channels and angiogenic sprouting from vascularized scar tissue, it is currently believed that laser-induced denervation plays a key role in symptomatic alleviation. Aside from the immediate postoperative anginal relief experienced by patients, the correlation between denervation and the absence of angina can be derived from clinical practice. For example, silent ischemia is frequently observed in patients with diabetic neuropathy and heart transplant patients do not experience angina postoperatively until the onset of myocardial reinnervation. Moreover, disappointing results of percutaneous myocardial revascularization may be attributed to the predominant epicardial localization of afferent sympathetic fibers.

The present work by Asai and colleagues [1] elegantly demonstrates that both transmyocardial laser revascularization and radiofrequency transmyocardial revascularization induce myocardial denervation. In conjunction with the many indications of anginal relief by transmyocardial laser revascularization-mediated denervation, the current findings underscore the necessity of developing strategies to optimize symptomatic reduction at minimal mortality rates. The results obtained by Asai and colleagues should therefore be considered another step in this direction. Table 1 in their article [1] suggests that treatment of basal segments may be more effective than treatment of other regions, corroborating earlier clinical findings by Al-Sheik's group and our group. A suitable, minimally invasive procedure for instilling basal damage could be for example the use of the Starfish cardiac positioner (Starfish 2 Heart Positioner, Medtronic, Inc, Minneapolis, MN) developed by Gründeman and colleagues [2] in combination with a laser procedure, radiofrequency or cryoablation, or simply with a surgical blade or scissors. Nevertheless, easier methods to influence myocardial innervation, such as spinal cord stimulation, may prove to be excellent alternatives.

On a final note, it is unfortunate that the initial lack of insight into the precise dynamics of transmyocardial laser revascularization constituted a deterring factor in the acceptance of a clinically effective therapy. On the other hand, there have been many examples of therapies that have been clinically accepted while knowledge of their underlying mechanism was limited. Apparently maturation of a therapy from an experimental status to a clinically accepted status is not only based on insight in its working mechanism.

	References

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1. Asai T, Yamamoto S, Ishino K, et al. Time-dependent regional myocardial denervation as a nonspecific response to transmyocardial laser revascularization Ann Thorac Surg 2005;80:1362-1370.[Abstract/Free Full Text]
2. Gründeman PF, Verlaan CW, van Boven WJ, Borst C. Ninety-degree anterior cardiac displacement in off-pump coronary artery bypass graftingthe Starfish cardiac positioner preserves stroke volume and arterial pressure. Ann Thorac Surg 2004;78:679-685.[Abstract/Free Full Text]

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