https://summitmd.com/pdf/syllabus/17-LASER_MYOCARDIAL_REVASCULARIZATION.pdf

A blinded, randomized, placebo-controlled trial of percutaneous laser myocardial revascularization to improve angina symptoms in patients with severe coronary disease.

Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines

This prospective, double-blind, randomized, sham-controlled trial was designed to control for patient and investigator bias in assessing symptomatic improvement after percutaneous myocardial laser revascularization (PMLR) therapy. Eighty-two patients with stable angina pectoris (class III or IV) not amenable to conventional revascularization and with evidence of reversible ischemia, ejection fraction >/=25%, and myocardial wall thickness >/=8 mm were randomized to either PMLR with optimal medical therapy (n = 40) or to a sham procedure with optimal medical therapy (n = 42). With the exception of 1 laser technician, all patients, investigators, and assessors were blinded to treatment through the 12-month follow-up. The primary end point was restricted to Canadian Cardiovascular Society angina class improvement to limit the number of patients exposed to a sham procedure. Secondary assessments included medication usage, quality of life, exercise testing, ejection fraction, and hospitalizations. The incidence of serious adverse events, as determined by cardiac event-free survival at 12 months, was similar between groups. At 12 months, Canadian Cardiovascular Society angina scores improved by >/=2 classes in significantly more PMLR-treated patients than sham control patients (35% vs 14%, p = 0.04). Angina-specific quality-of-life measures were significantly higher in the PMLR group at each follow-up (p <0.05). Exercise and medication usage was similar between groups at 12 months. We conclude that PMLR therapy is reasonably safe and effective as symptomatic improvement in patients refractory to medical therapy, and that the clinical benefit is not attributable to placebo effect or investigator bias.

Usefulness and safety of percutaneous myocardial laser revascularization for refractory angina pectoris.

Despite significant advances in revascularization techniques and medical therapy, there remains a significant population of patients who continue to have intractable angina symptoms. This review aims to define the patients with refractory angina pectoris (RAP) and to present the therapeutic options currently available for this condition. RAP itself is defined and the pharmacological treatment options other than traditional medical therapies are discussed. The latest therapeutic options for this patient population are extensively reviewed. Among the multitude of pharmacological and non-invasive therapeutic options for patients with RAP, ranolazine is a new drug indicated for the treatment of chronic angina, in combination with amlodipine, beta-blockers or nitrates. Enhanced external counterpulsation has not only been shown to improve symptoms, but also to improve long-term ventricular function in these patients. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Transmyocardial laser revascularization has emerged as an invasive treatment for RAP over the last two decades. Extracorporeal shockwave myocardial revascularization gene therapy and percutaneous in situ coronary venous arterialization are still under investigation. (Cardiol J 2011; 18, 4: 343–351)

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Management of refractory angina pectoris

Combined analysis of the electrical and mechanical function of the heart holds promise as a means of acquiring a better understanding of a variety of cardiac diseases that ultimately may lead to heart failure. The NOGA® XP Cardiac Navigation System is a unique, nonfluoroscopic, catheter-based technology that achieves real-time acquisition of three-dimensional, endoventricular electromechanical maps. Through the provision of point-by-point measurements of endocardial electrical activation and voltage and mechanical shortening, electromechanical mapping has been evaluated for its ability to identify regional myocardial ischemia and characterize tissue viability. A decade of preclinical and clinical research has verified its safety and feasibility and raised the possibility of its application as a diagnostic adjunct to conventional angiography in the catheterization laboratory. However, this role has not yet been realized outside of the research setting. Instead, a more prominent niche for NOGA® XP has emerged as a therapeutic tool for guiding direct myocardial interventions, most notably the targeted administration of regenerative therapies (e.g., cells, genes) to the heart. In this review, we discuss the fundamental aspects of this electromechanical mapping system and the evidence for both its diagnostic and therapeutic utility.

Endoventricular Electromechanical Mapping—The Diagnostic and Therapeutic Utility of the NOGA® XP Cardiac Navigation System

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Lou S. McKeever

Papers

One-year results of percutaneous myocardial revascularization for refractory angina pectoris