PubMed · 7059728
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M J Goldberg. 1982. Left ventricular aneurysm.. https://pubmed.ncbi.nlm.nih.gov/7059728/
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Dr. Mahmood Mirhoseini from Milwaukee, WI, transformed transmyocardial revascularization (TMR) into transmyocardial laser revascularization (TMLR) more than 2 decades ago. The controversial nature of this laser procedure and the prospect of its successful application to refractory cases of chronic debilitating angina have created spirited interest in TMLR. As a natural component of this interest, various laser modalities have been proposed and employed during the performance of the TMLR procedure both in the experimental and the clinical setting. However, it is the nature of laser-tissue interactions that is primarily responsible for the long-term fate of the channels, the angiogenesis that occurs in the vicinity of these laser channels, and the resulting increase (if any) in myocardial perfusion. These interactions with tissue are, in turn, determined by laser variables such as photonic absorption and scattering by the target tissue, pulse energy and duration, and the peak power generated. The CO2 laser has the advantages of producing high-energy pulses that create a transmural channel with a single pulse, low-peak power that minimizes structural tissue trauma, and high photonic absorption to minimize thermal damage. The holmium:YAG and excimer lasers, in turn, have the advantage of being coupled to a fiber optic catheter for transluminal endocardial delivery. Importantly, long-term clinical and perfusional data showing a cause and effect relationship between the use of TMLR and these end-points are available for the CO2 laser only. Prospective randomized trials are, therefore, warranted to delineate the use of each laser modality in relation to that of the CO2 laser in the TMLR setting.
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PURPOSE: TI-201 myocardial perfusion SPECT is commonly used to assess myocardial perfusion and viability. Nitrate-augmented redistribution with repeated injection facilitates the detection of reversible segments compared with standard redistribution. In this study, we investigated the potential of nitrate augmentation to improve myocardial perfusion and viability assessment without repeated injection and we also compared nitrate-augmented redistribution with delayed redistribution. METHODS: Eighteen patients underwent a stress-redistribution TI-201 SPECT study. Immediately after redistribution SPECT, each patient was administered 0.6 mg glyceryl trinitrate and nitrate-augmented redistribution SPECT acquired 30 minutes later. Each patient then returned the next day and was injected with a booster dose of TI-201 30 minutes before the delayed redistribution SPECT acquisition. For each SPECT study, the myocardium was divided into 11 segments, and perfusion to each segment was scored on a four-point scale by consensus. An overall cardiac perfusion score was derived by summing the perfusion score for each segment. RESULTS: Reduced stress perfusion was identified in 150 segments: 23 (15.3%) had improved perfusion after redistribution; 60 (40%) segments had improved perfusion after nitrate-augmented redistribution; 52 (34.7%) segments with reduced stress perfusion had improved perfusion after delayed redistribution. The cardiac perfusion score after stress was 15.9+/-5.5 (means+/-SD). The score increased to 17.4+/-5.4 after redistribution. The perfusion score improved to 19.7+/-5.8 (P < 0.05 versus redistribution) after nitrate augmentation. The cardiac perfusion score, 19.2+/-6.4, did not improve further after delayed redistribution. CONCLUSIONS: TI-201 SPECT with nitrate-augmented redistribution is as good or better than delayed redistribution with repeated injection for myocardial perfusion and viability assessment. TI-201 SPECT with nitrate-augmented redistribution has significant logistical and economic advantages over traditional delayed redistribution with TI-201 repeated injection.