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Coronary revascularization in heart transplant recipients by excimer laser angioplasty
1Interventional Cardiovascular Laboratories, McGuire VA Medical Center, Division of Cardiology, Medical College of Virginia/Virginia Commonwealth University, Richmond, Virginia 23249, USA.
Insights
Excimer laser angioplasty effectively treats obstructive coronary lesions in heart transplant recipients, offering a safe alternative to balloon angioplasty for allograft coronary artery disease. Further studies are needed to confirm long-term outcomes.
Area of Science:
- Cardiology
- Transplantation Medicine
- Interventional Cardiology
Background:
- Allograft coronary artery disease (ACAD) is a leading cause of mortality in heart transplant recipients.
- Percutaneous balloon angioplasty is often suboptimal for complex ACAD lesions.
- Excimer laser angioplasty has shown promise for atherosclerotic plaque removal in native coronary arteries.
Observation:
- A pilot study evaluated excimer laser coronary angioplasty (ELCA) in six heart transplant recipients with 10 obstructive ACAD lesions.
- Procedures utilized specific laser parameters and techniques, including adjunct balloon angioplasty and stenting in most cases.
- Angiographic assessment confirmed successful lesion recanalization and luminal patency post-procedure.
Findings:
- ELCA achieved significant reduction in stenosis, from 92% pre-procedure to 35% after laser and 2% post-adjunct procedures.
- No major periprocedural or in-hospital complications were observed.
- The 6-month restenosis rate was 22%.
Implications:
- Percutaneous excimer laser angioplasty appears to be a safe and effective treatment for focal obstructive ACAD lesions.
- These findings support further investigation in larger, randomized clinical trials.
- ELCA may offer a valuable revascularization option for heart transplant recipients with complex coronary artery disease.
Background And Objective:
Aggressive development of allograft coronary artery disease is a major cause of death in heart transplant recipients. Percutaneous balloon angioplasty is considered suboptimal for complex lesions in native coronary vessels and heart transplant recipients, alike. Excimer laser energy (308-nm wavelength) can successfully remove and vaporize atherosclerotic plaques in native coronary vessels; however, its application in heart transplant recipients has not been studied clinically yet.
Study Design/Materials And Methods:
Six heart transplant recipients underwent percutaneous excimer laser (CVX-300, Spectranetics, Colorado Springs, CO) coronary angioplasty for treatment of a total of 10 discrete, obstructive coronary artery lesions. By using concentric or eccentric multifiber laser catheters, energy parameters were set at a fluence of 45 mJ/mm(2) or 60 mJ/mm(2) with a frequency of 25 Hz and 40 Hz, respectively, with a pulse duration of 135 ns and output of 200 mJ/pulse. The "saline flush" and "pulse and retreat" lasing techniques were used. In each case, adjunct balloon angioplasty was performed; in five lesions, an intracoronary stent was implanted. Angiographic evaluation was performed by visual assessment.
Results:
Each procedure was successful as defined by laser recanalization of the target lesion (reduction of target lesion stenosis in more than 20%) and subsequent adequate final luminal patency (reduction of target lesion stenosis to less than 50%) and absence of any major in-cardiac catheterization complication (such as perforation, acute closure, dissection, emergency coronary artery bypass surgery), or in-hospital complications (such as death, myocardial infarction, cardiac enzyme elevation, major bleeding), or need for surgical revascularization. A 92 +/- 5% preprocedural percent diameter stenosis was reduced by laser to 35 +/- 16% and by adjunct balloon angioplasty in all lesions and stenting in five lesions, to final residual stenosis of 2 +/- 6%. Angiographic follow-up between 2 and 6 months after the procedure demonstrated a target lesion restenosis rate of 22%.
Conclusion:
Percutaneous excimer laser is safe and efficacious in the treatment of focal obstructive lesions caused by allograft coronary artery disease. These data represent an early clinical experience; thus, the long-term outcome of this revascularization method in recipients of heart transplantation will have to be determined by a large scale prospective, randomized, multicenter clinical study.
