Topaz O, Janin Y, Bernardo N, Bailey N T, Mohanty P K
Interventional Cardiovascular Laboratories, McGuire VA Medical Center, Division of Cardiology, Medical College of Virginia/Virginia Commonwealth University, Richmond, Virginia 23249, USA.
Lasers Surg Med. 2000;26(5):425-31. doi: 10.1002/1096-9101(2000)26:5<425::aid-lsm1>3.0.co;2-x.
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.
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%.
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.
同种异体移植冠状动脉疾病的快速发展是心脏移植受者死亡的主要原因。经皮球囊血管成形术被认为对于自体冠状动脉血管和心脏移植受者的复杂病变均不是最佳选择。准分子激光能量（波长308纳米）能够成功去除并汽化自体冠状动脉血管中的动脉粥样硬化斑块；然而，其在心脏移植受者中的应用尚未进行临床研究。
研究设计/材料与方法：6名心脏移植受者接受了经皮准分子激光（CVX - 300，Spectranetics公司，科罗拉多斯普林斯，科罗拉多州）冠状动脉血管成形术，以治疗总共10处离散的、阻塞性冠状动脉病变。通过使用同心或偏心多光纤激光导管，能量参数设置为能量密度45 mJ/mm²或60 mJ/mm²，频率分别为25 Hz和40 Hz，脉冲持续时间为135纳秒，输出为200 mJ/脉冲。采用了“盐水冲洗”和“脉冲与回撤”激光技术。在每种情况下，均进行了辅助球囊血管成形术；在5处病变中植入了冠状动脉支架。通过视觉评估进行血管造影评估。
按照目标病变激光再通（目标病变狭窄减少超过20%）、随后最终管腔通畅良好（目标病变狭窄减少至小于50%）以及无任何主要的心内导管插入术并发症（如穿孔、急性闭塞、夹层、急诊冠状动脉搭桥手术）、或院内并发症（如死亡、心肌梗死、心肌酶升高、大出血）、或无需外科血管重建来定义，每个手术均成功。术前直径狭窄百分比为92±5%，通过激光治疗在所有病变中以及在5处病变中通过辅助球囊血管成形术和支架植入，最终残余狭窄为2±6%。术后2至6个月的血管造影随访显示目标病变再狭窄率为22%。
经皮准分子激光治疗同种异体移植冠状动脉疾病引起的局灶性阻塞性病变是安全有效的。这些数据代表了早期临床经验；因此，这种血管重建方法在心脏移植受者中的长期结果将必须通过大规模前瞻性、随机、多中心临床研究来确定。
