Allan M. Lansing

Transmyocardial laser revascularization: Results of a multicenter trial with transmyocardial laser revascularization used as sole therapy for end-stage coronary artery disease ☆ ☆☆ ★ ★★ ♢

BACKGROUND Transmyocardial laser revascularization was used as the sole therapy for patients with ischemic heart disease not amenable to percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. This technique uses a carbon dioxide laser to create transmyocardial channels for direct perfusion of the ischemic heart. METHODS Since 1992, 200 patients, at eight hospitals in the United States, have undergone transmyocardial laser revascularization. The patients have a combined 1560 months of follow-up for an average of 10 +/- 3 months per patient. Their age was 63 +/- 10 years and their ejection fraction was 47% +/- 12%. Eighty-two percent had at least one previous bypass graft operation and 38% had a prior angioplasty. Preoperatively, the patients underwent nuclear single photon emission computed tomography perfusion scans to identify the extent and severity of their ischemia. These scans were repeated at 3, 6, and 12 months. Angina class, admissions for angina, and medications were recorded. RESULTS The perioperative mortality was 9%. Angina class decreased significantly from before treatment to 3, 6, and 12 months (p < 0.001). Likewise, there was a significant decrease in the number of perfusion defects in the treated left ventricular free wall. Concomitantly, there was a significant decrease in the number of admissions for angina in the year after the procedure when compared with the year before treatment (2.5 vs 0.5 admissions per patient-year). CONCLUSION These combined results indicate that transmyocardial laser revascularization provides angina relief, decreases hospital admissions, and improves perfusion in patients with severe coronary artery disease.

Treatment of cardiogenic shock with the hemopump left ventricular assist device

A multiinstitutional study is in progress to evaluate the Hemopump in the treatment of cardiogenic shock. Fifty-three patients with refractory cardiogenic shock were selected for Hemopump assistance. The hemodynamic definition of cardiogenic shock included (1) a cardiac index of less than 2.0 L.min-1.m-2, (2) pulmonary capillary wedge pressure of greater than 18 mm Hg, and (3) a systolic blood pressure of less than 90 mm Hg or a left ventricular work index of less than 1,500 g-m.m-2.min-1. The Hemopump was successfully inserted in 41 of 53 patients (77.3%). A significant improvement in the hemodynamic status was seen during Hemopump assistance. A minimal level of hemolysis was observed. No leg ischemia was observed. The 30-day overall survival of the Hemopump group was 31.7%. Criteria establishing indications for use and clinical utility are proposed. We conclude that the Hemopump provides significant hemodynamic support of the patient in cardiogenic shock allowing for recovery from ventricular stunning in marginal ventricles, and that in select patients the Hemopump may offer a major improvement in survival over conventional therapy.

Transmyocardial laser revascularization in the patient with unmanageable unstable angina

BACKGROUND Transmyocardial laser revascularization (TMR) provides relief for patients with chronic angina, nonamenable to direct coronary revascularization. Unmanageable, unstable angina (UUA) defines a subset of patients with refractory angina who are at high risk for myocardial infarction and death. Patients were classified in the UUA group when they had been admitted to the critical care unit with unstable angina for 7 days with three failed attempts at weaning them off intravenous antianginal medications. METHODS Seventy-six treated patients were analyzed to determine if TMR is a viable option for patients with unmanageable unstable angina. These patients were compared with 91 routine protocol patients (protocol group [PG]) undergoing TMR for chronic angina not amenable to standard revascularization. The procedure was performed through a left thoracotomy without cardiopulmonary bypass. These patients were followed for 12 months after the TMR procedure. Both unmanageable and chronic angina patients had a high incidence of at least one prior surgical revascularization (87% and 91%, respectively). RESULTS Perioperative mortality (< or = 30 days post-TMR) was higher in the UUAG versus PG (16% vs 3%, p = 0.005). Late mortality, up to 1 year of follow-up, was similar (13% vs 11%, UUAG vs PG; p = 0.83). A majority of the adverse events in the UUAG occurred within the first 3 months post-TMR, and patients surviving this interval did well, with reduced angina of at least two classes occurring in 69%, 82%, and 82% of patients at 3, 6, and 12 months, respectively. The percent improvement in angina class from baseline was statistically significant at 3, 6, and 12 months. A comparable improvement in angina was found in the protocol group of patients. CONCLUSIONS TMR carried a significantly higher risk in unmanageable, unstable angina than in patients with chronic angina. In the later follow-up intervals, however, both groups demonstrated similar and persistent improvement in their angina up to 12 months after the procedure. TMR may be considered in the therapy of patients with unmanageable, unstable angina who otherwise have no recourse to effective therapy in the control of their disabling angina.

Left Atrial-Left Ventricular Bypass for Congenital Mitral Stenosis

The case of a patient with congenital mitral stenosis successfully treated by insertion of a left atrial-left ventricular valved conduit is presented. After insertion of the conduit, pulmonary artery pressure was normal, persistent pulmonary edema and ascites disappeared, and the childs rate of growth and level of activities returned to normal.

Evolution of clinical, radiological, and electrocardiographic changes following experimental atrial septal defect

Abstract Incomplete RBBB associated with atrial septal defect is a developmental abnormality that results from mild right ventricular hypertrophy, particularly in the outflow tract region. This electrocardiographic finding appeared five to ten months after surgical creation of the atrial defect in eight puppies. At 11 months, widening of the QRS appeared suddenly at the same time that the pulmonary valve closure became louder, sharper, and delayed so that the defect could be detected clinically. Gradual spontaneous narrowing of a surgically created atrial septal defect in the experimental animal was suspected from the appearance of respiratory variation in splitting of the second sound, even though the splitting was still greater than normal. Complete spontaneous closure of the defect in the experimental animal or surgical repair in man is immediately followed by decreased intensity and a softer quality of the pulmonary component of the second heart sound, although the radiological and electrocardiographic evidence of the previous defect persists.

Mitral regurgitation and intramyocardial injection resulting from left heart catheterization

Abstract The incidence of mitral regurgitation and intramyocardial injection of contrast material during left heart catheterization in normal dogs has been investigated, comparing the transseptal with the retrograde aortic approach. A transseptal catheter passed through the mitral valve into the left ventricle almost always caused some regurgitation during injection of contrast material, even in the absence of premature ventricular contractions. There was a 33 per cent incidence of intramyocardial injection when the transseptal catheter was employed. Retrograde aortic catheterization was associated at times with minimal mitral regurgitation when premature ventricular contractions occurred during injection, but significant mitral regurgitation was never produced. In the absence of premature contractions, regurgitation did not occur. Intramyocardial injection of contrast material was not observed in this series when the retrograde aortic catheter was employed.

A simplified technique for performing the Waterston shunt.

Abstract The Waterston shunt is preferred by many surgeons for palliative treatment of cyanotic congenital heart disease with decreased pulmonary blood flow. Technical problems such as control of the proximal right pulmonary artery, suturing of the back row of the anastomosis, angulation of the right pulmonary artery, and creation of an exact orifice size have decreased its appeal. A simplified technique was developed that has shortened the operative time and almost eliminated the difficulties of pulmonary artery anastomosis.