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Catheter-based percutaneous myocardial laser revascularization in patients with end-stage coronary artery disease
1Klinik für Innere Medizin/Kardiologie, Universität Leipzig-Herzzentrum GmbH, Leipzig, Germany. laub@server.3.medizin.uni-leipzig.de
Insights
This study shows percutaneous myocardial revascularization (PMR) is a safe and feasible treatment for severe coronary artery disease (CAD) and angina. PMR significantly improved patient symptoms and exercise capacity, though myocardial perfusion evidence was lacking.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Technology
Background:
- Transmyocardial laser revascularization (TMR) offers an alternative for patients with end-stage coronary artery disease (CAD) and intractable angina unresponsive to conventional treatments.
- Traditional TMR requires surgical thoracotomy, associated with significant morbidity and mortality.
- A novel catheter-based system for percutaneous myocardial revascularization (PMR) has been developed to mitigate these risks.
Purpose of the Study:
- To evaluate the feasibility and safety of a novel catheter-based laser system for PMR.
- To analyze the initial clinical outcomes, including acute and long-term results, in patients with severe CAD and refractory angina pectoris.
- To assess the impact of PMR on angina symptoms and exercise capacity.
Main Methods:
- A catheter-based Holmium: YAG laser system was employed to create channels in the myocardium from the left ventricular cavity.
- The laser energy was delivered via a flexible optical fiber through a coaxial catheter system, maneuvered under biplane fluoroscopy.
- Thirty-four patients with severe CAD and Canadian Cardiologic Society (CCS) Angina Scale Class III-IV, unsuitable for coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), were included.
Main Results:
- The PMR procedure was successfully completed in all 34 patients, with 8-15 channels created per ischemic region.
- A single major periprocedural complication of arterial bleeding requiring surgical repair occurred.
- At 6-month follow-up, significant improvements were observed in angina pectoris (CCS class reduced from 3.0 to 1.3, p<0.0001) and exercise capacity (exercise time increased by 33%, p<0.05).
- One early death occurred due to myocardial infarction in a non-treated region.
Conclusions:
- Percutaneous myocardial revascularization (PMR) represents a safe and feasible therapeutic option for patients with end-stage CAD and severe angina pectoris who are not candidates for CABG or PTCA.
- Initial clinical results demonstrate immediate and significant improvements in symptoms and exercise capacity following PMR.
- Further investigation is needed to demonstrate improved myocardial perfusion following PMR.
Objectives:
This study evaluates the feasibility and safety of a catheter-based laser system for percutaneous myocardial revascularization and analyses the first clinical acute and long-term results in patients with end-stage coronary artery disease (CAD) and severe angina pectoris.
Background:
In patients with CAD and intractable angina who are not candidates for either coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), transmyocardial laser revascularization (TMR) has been developed as a new treatment that results in reduced angina pectoris and increased exercise capacity. However, surgical thoracotomy is required for TMR with considerable morbidity and mortality.
Methods:
A catheter-based system has been developed that allows creation of laser channels in the myocardium from within the left ventricular cavity. Laser energy generated by a Holmium: YAG (Cardiogenesis Corporation, Sunnyvale, California) laser was transmitted to the myocardium via a flexible optical fiber capped by an optic lens. The optical fiber was maneuvered to the target area under biplane fluoroscopy through a coaxial catheter system permitting movement in three dimensions.
Results:
Thirty-four patients with severe CAD not amenable to either CABG or PTCA and refractory angina pectoris (Canadian Cardiologic Society [CCS] Angina Scale Class III-IV) were included in the study. Ischemic regions were identified by coronary angiography and confirmed by thallium scintigraphy. The percutaneous myocardial revascularization (PMR) procedure was successfully completed in all patients. In 29 patients, one vascular territory of the left ventricle and in 5 patients, two vascular territories were treated. Eight to fifteen channels were created in each ischemic region. Major periprocedural complications were limited to an episode of arterial bleeding requiring surgical repair. There was one death early after PMR, due to a myocardial infarction (MI) in a nontreated region. Clinical follow-up at 6 months (17 patients) demonstrated significant improvement of angina pectoris (CCS class before PMR: 3.0+/-0.0, six months after PMR: 1.3+/-0.8, p<0.0001) and increased exercise capacity (exercise time on standard bicycle ergometry before PMR: 384+/-141 s, six months after PMR: 514+/-158 s, p<0.05), but thallium scintigraphy failed to show improved perfusion of the laser treated regions.
Conclusions:
Percutaneous myocardial revascularization is a new safe and feasible therapeutic option in patients with CAD and severe angina pectoris not amenable to either CABG or PTCA. Initial results show immediate and significant improvement of symptoms and exercise capacity but evidence of improved myocardial perfusion is still lacking.