ISBN: 3540676546
TITLE: Lasers for Ischemic Heart Disease
AUTHOR: Mueller, Xavier M.
TOC:

Introduction 1
1 Historical Background
1.1 First Approaches: Extracardiac Operations for Angina 2
1.2 The Transition Era: From Indirect to Direct Revascularization Procedures 2
1.2.1 The Indirect Procedures 2
1.2.2 The Vineberg Procedure 3
1.3 Direct Coronary Artery Revascularization Procedures 4
1.3.1 The Pioneers 4
1.3.2 Early Forms of Direct Coronary Artery Surgical Procedures 4
1.3.3 The Golden Age of CABG 5
1.3.4 A New Nonsurgical Direct Approach: Percutaneous Transluminal Coronary Angioplasty (PTCA) 5
1.4 The Reappraisal of Indirect Myocardial Revascularization 6
1.4.1 Transmyocardial Revascularization: From Needle to Laser 6
1.4.2 Therapeutic Angiogenesis 6
1.4.3 Neurostimulation 7
2 Microvascular Anatomy of the Heart
2.1 Introduction 8
2.2 Direct Communication with Heart Chambers and Sinusoids 8
2.2.1 Thebesian Vessels and the Quest for Direct Communications with Heart Chambers 8
2.2.2 The Emergence of the Sinusoid Concept 10
2.2.3 Myocardial Sinusoids: Myth or Reality 12
2.3 Myocardial Capillaries 13
2.4 Collateral Circulation of the Heart 14
2.4.1 Intercoronary Anastomoses 14
2.4.2 Extracardiac Anastomoses 16
2.5 Microvasculature Anatomy in Ischemic Heart Disease 18
3 The Vineberg Procedure:A Forgotten Operation?
3.1 Introduction 19
3.2 Scientific Bases 19
3.2.1 Anatomy of Myocardial Microcirculation 19
3.2.2 Distribution of Coronary Artery Disease 20
3.2.3 Specificity of the IMA as a Conduit 20
3.3 Experimental Work 20
3.3.1 The Original Procedure 20
3.3.2 Adjuncts to the Original Procedure 22
3.3.3 Renewed Experimental Interest in the Original Vineberg Concept 23
3.4 Technical Aspects of the Vineberg Procedure 25
3.4.1 Patient Preparation and Access to the Operative Field 25
3.4.2 IMA Mobilization 25
3.4.3 Heart Exposure 26
3.4.4 Making of Intramyocardial Tunnel 26
3.4.5 Implantation of the IMA 26
3.5 Clinical Data 27
3.5.1 Early Clinical Results 27
3.5.2 The Placebo Criticism and the Need for Objective Evidence 27
3.5.3 Arteriographic Evidence 28
3.5.4 The Advent of the Vineberg Procedure 28
3.5.5 Physiologic Evidence 29
3.5.6 Patient Selection Criteria 29
3.5.7 Abandonment of the Procedure 30
3.5.8 Late Results 30
3.6 Vineberg and the Sinusoid Concept 32
3.7 Conclusions 33
4 Myocardial Acupuncture:The Immediate Forerunner of Transmyocardial Laser Revascularization
4.1 The Reptilian Heart Concept 34
4.2 Sen's Pioneer Experimental Work 34
4.3 Other Experimental Work 36
4.4 Clinical Application 39
4.5 Renewed Experimental Interest in Transmyocardial Acupuncture 39
5 Laser Physics
5.1 Introduction 41
5.2 Fundamentals 41
5.2.1 Ordinary Light Sources 41
5.2.2 Laser Light 42
5.3 The Physical Process of Laser Action 44
5.3.1 Spontaneous Emission of Radiation 44
5.3.2 Absorption of Radiation 44
5.3.3 Stimulated Emission of Electromagnetic Radiation 44
5.3.4 Absorption and Amplification of Light 45
5.3.5 Population Inversion and Laser Media 45
5.4 Laser Devices 46
5.5 Types of Lasers 47
5.5.1 CO_2 Lasers 47
5.5.2 Ho:YAG Laser 49
5.5.3 Excimer Laser 49
5.6 The Ho:YAG Cardio Genesis System 49
6 Laser Interaction with Tissue
6.1 Laser Interaction with Tissue: General Consideration 55
6.1.1 Qualitative Interaction 55
6.1.2 Quantitative Interaction 55
6.1.3 Reflection, Absorption, and Scattering 56
6.1.4 General Characteristics of Laser Beams Used in TMLR 57
6.1.5 Thermal Interaction 58
6.1.6 Nonthermal Interaction 61
6.2 Laser Interaction with Tissue During TMLR 61
6.2.1 CO_2 Lasers 61
6.2.2 Ho:YAG Lasers 64
6.2.3 Excimer Laser 65
6.2.4 Comparison of Tissue Injury Resulted in the Three Types of Laser 65
6.2.5 Extent of Laser-Mediated Injury 65
7 Transmyocardial Laser Revascularization:Patient Selection, Operative Technique, and Perioperative Care
7.1 Patient Selection and Preoperative Evaluation 68
7.2 Contraindications 69
7.3 Patient Preparation for the Operation 69
7.4 Operative Technique 70
7.4.1 Surgical Approach 70
7.4.2 Operating Procedure 71
7.4.3 Channel Density 72
7.4.4 Area of Treatment 72
7.4.5 Postoperative Care 72
8 The Pioneering Era of Transmyocardial Laser Revascularization
8.1 Experimental Data 74
8.1.1 Infarction Reduction and Improved Survival in the Canine Model 74
8.1.2 Other Animal Models, Other Results 75
8.2 Initial Clinical Applications of TMLR 76
9 Laser Channel Morphology
9.1 Introduction 77
9.2 Experimental Studies in Normal Myocardium 77
9.2.1 CO_2 Laser 77
9.2.2 Ho:YAG Laser in a Pig Model 79
9.2.3 Excimer Laser 84
9.2.4 Comparative Studies 85
9.2.5 Conclusions 87
9.3 Experimental Studies in Acutely Ischemic Myocardium 87
9.3.1 CO_2 Laser 87
9.3.2 Ho:YAG Laser 88
9.3.3 Excimer Laser 91
9.3.4 Conclusions 91
9.4 Experimental Studies in Chronically Ischemic Myocardium 92
9.4.1 Ho:YAG Laser 92
9.4.2 Comparative Study: CO_2 Versus Ho:YAG 92
9.4.3 Conclusions 92
9.5 Clinical Findings 92
9.5.1 Reports Suggesting Channel Patency 93
9.5.2 Reports Suggesting That Channels Do Not Remain Patent 94
9.5.3 Conclusions 95
10 Pathophysiology of Transmyocardial Laser Revascularization
10.1 Introduction 96
10.2 Relationship of Intramyocardial and Intraventricular Pressure 96
10.3 Is There Blood Flow Through the Channels? 98
10.3.1 Experimental Studies 98
10.3.2 Clinical Studies 102
10.3.3 Conclusions 103
10.4 Angiogenesis and TMLR 104
10.4.1 Acute Studies 104
10.4.2 Chronic Studies 106
10.4.3 Morphometric Analysis of Neovascularization in a Pig Model 109
10.4.4 Conclusions 124
10.5 TMLR and Nerve Destruction 125
10.5.1 Transmural Laser Channels 125
10.5.2 Nontransmural Laser Channels 126
10.5.3 Clinical Study 127
10.6 TMLR and Scar Retraction 127
10.6.1 Material and Methods 127
10.6.2 Results 127
10.6.3 Discussion 130
10.7 The Placebo Effect 132
11 Clinical Results of Transmyocardial Laser Revascularization
11.1 Introduction 133
11.2 CO_2 Laser 133
11.2.1 The Pioneer Work of Mirhoseini 133
11.2.2 The Texas Heart Institute Experience 134
11.2.3 The Initial Brigham and Women's Hospital Experience 135
11.2.4 The First United States Multicenter Study 135
11.2.5 The Hamburg University TMLR Trial: A Long-Term Follow-up 136
11.2.6 The Lake Constance Heart Center Experience: The Largest Single-Institution Series 137
11.2.7 The Cambridge Study: A Single-Center Randomized Controlled Trial 138
11.2.8 A U.S. Multicenter Randomized Controlled Trial 139
11.2.9 The European and Asian International Registry Report 140
11.2.10 An Indian Trial with a Younger Patient Population 141
11.2.11 TMLR as an Adjunct to Minimally Invasive CABG 142
11.3 Ho:YAG Laser 144
11.3.1 The Initial Leipzig Group Experience 144
11.3.2 The Pisa Group Initial Experience 144
11.3.3 The Houston Randomized Series 145
11.3.4 ATLANTIC: A U.S. Multicenter Randomized Control Trial 146
11.3.5 A U.S. Multicenter Randomized Controlled Trial with Refractory Class 4 Angina Patients 147
11.4 Excimer Laser 148
11.5 Other Indications of TMLR 148
11.5.1 Unstable Angina 148
11.5.2 Cardiac Transplantation Allograft Vasculopathy 149
12 Transmyocardial Laser Revascularization and Left Ventricular Function
12.1 Introduction 151
12.2 Experimental Data 151
12.2.1 CO_2 Laser 151
12.2.2 Ho:YAG Laser 154
12.3 Clinical Studies 161
12.3.1 Left Ventricular Function as a Risk Factor 161
12.3.2 Left Ventricular Function as an Outcome 161
13 Adverse Effects of Transmyocardial Laser Revascularization
13.1 Introduction 163
13.2 Perioperative Morbidity and Mortality 163
13.3 Arrhythmias 165
13.3.1 Intraoperative Arrhythmias 165
13.3.2 Postoperative Arrhythmias 166
13.4 Microembolization 166
13.5 Left Ventricular Function 167
13.6 Outcome after TMLR Cannot be Predicted by Peroperative Hemodynamics 167
13.6.1 Material and Methods 167
13.6.2 Results 168
13.6.3 Discussion 169
14 Alternatives Forms of Transmyocardial Laser Revascularization
14.1 Introduction 175
14.2 The Endoventricular Approach 175
14.2.1 Experimental Data 175
14.2.2 Preliminary Clinical Data 176
14.2.3 Catheter Navigational Control: A Look into the Future 177
14.3 The Thoracoscopic Approach 178
14.3.1 Experimental Data 178
14.3.2 First Clinical Cases 178
15 Angiogenesis:Pathophysiology
15.1 Introduction 179
15.2 Mechanisms of Blood Vessel Formation 179
15.3 Angiogenic Growth Factors 180
15.3.1 Fibroblast Growth Factor 180
15.3.2 Vascular Endothelial Growth Factor 181
15.3.3 Scatter Factor/Hepatocyte Growth Factor 182
15.3.4 Platelet-Derived Growth Factor 183
15.3.5 Transforming Growth Factor 183
15.3.6 Nitric Oxide 184
15.3.7 Heparin 184
15.3.8 Antiangiogenic Factors 185
15.4 Embryogenesis 185
15.4.1 Vasculogenesis and Angiogenesis 185
15.4.2 Molecular Regulators of Vascular Formation in the Embryo 185
15.5 Collateral Development 186
15.6 Occlusive Vascular Disease and Vascular Injury 187
15.6.1 Atherosclerotic Plaque 188
15.6.2 VEGF and bFGF in the Response to Vessel Injury 188
15.6.3 Reendothelialization after Intimal Injury and Hyperplasia 189
15.7 Criteria for Angiogenesis 189
16 Therapeutic Angiogenesis:The Basis
16.1 Introduction 190
16.2 Choice of Growth Factor 190
16.3 Potential Side Effects of Therapeutic Angiogenesis 191
16.4 Type and Method of Delivery 192
16.4.1 Recombinant Protein 192
16.4.2 Gene Therapy 192
16.4.3 Delivery Systems for Angiogenesis by Gene Transfer 194
16.4.4 Gene Expression Control 195
17 Therapeutic Angiogenesis:Results
17.1 Introduction 196
17.2 Animal Studies 196
17.2.1 Heparin 196
17.2.2 The Fibroblast Growth Factor Family 197
17.2.3 Vascular Endothelial Growth Factor 200
17.2.4 Fibroblast and Vascular Endothelial Growth Factors: Combined Administration 201
17.2.5 Scatter Factor/Hepatocyte Growth Factor 202
17.3 Human Studies 202
17.3.1 Heparin 202
17.3.2 FGF and VEGF 203
18 Combined Therapy:Transmyocardial Laser Revascularization and Therapeutic Angiogenesis
18.1 Introduction 206
18.2 Transmyocardial Laser Revascularization Associated with Administration of "Classical" Growth Factors 206
18.3 Improved Angiogenesis in TMLR Combined with Bone Protein Growth Factors Mixture 208
18.3.1 Material and Methods 208
18.3.2 Results 209
18.3.3 Discussion 209
19 Neurostimulation
19.1 Introduction 210
19.2 Underlying Mechanism 210
19.3 Neurostimulation Treatment Modalities 211
19.3.1 Transcutaneous Electrical Nerve Stimulation 211
19.3.2 Spinal Cord Stimulation 211
19.4 Patient Selection 211
19.5 Safety Aspects 212
19.6 Effects of Neurostimulation on Myocardial Physiology and Ischemia 212
19.7 Effects of Neurostimulation on the Autonomic Nervous System 213
19.8 Clinical Results 213
19.9 Conclusions 215
Conclusions 216
References 217
Abbreviations 239
Subject Index 241
END
