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J Am Coll Cardiol, 2003; 41:173-183
© 2003 by the American College of Cardiology Foundation
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STATE-OF-THE-ART PAPER

Myocardial laser revascularization for the treatment of end-stage coronary artery disease

Mehrdad Saririan, MD* and Mark J. Eisenberg, MD, MPH, FACC{dagger},*

* Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
{dagger} Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada

Manuscript received February 14, 2002; revised manuscript received June 26, 2002, accepted August 29, 2002.

* Reprint requests and correspondence: Dr. Mark J. Eisenberg, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Côte St. Catherine Road, Room A-118, Montreal, Quebec H3T 1E2, Canada.
marke{at}epid.jgh.mcgill.ca

Myocardial laser revascularization is a novel therapeutic technique aimed at delivering oxygenated blood via a series of channels to the ischemic regions of the heart. These channels may be created surgically or via a less invasive percutaneous approach. In patients with end-stage coronary artery disease, both transmyocardial laser revascularization (TMR) and percutaneous myocardial laser revascularization (PMR) have been associated with a reduction in symptoms, improved exercise tolerance, and enhanced quality of life. However, the mechanism of action of laser therapy is incompletely understood, the results of objective cardiac perfusion measurements are inconclusive, and multiple randomized trials have failed to demonstrate an increase in survival. In addition, the positive results seen in TMR trials have been questioned because of a lack of blinding, raising the possibility that the benefit may have been due to the placebo effect. Finally, two recent sham-controlled, randomized clinical trials of PMR have not shown any benefit of the procedure, but instead have highlighted the important role of the placebo effect in the response to PMR. Further research is, therefore, needed to elucidate the value of myocardial laser revascularization.

Abbreviations and Acronyms
  BELIEF
  Blinded Evaluation of Laser Intervention Electively for Angina Pectoris trial
  CABG
  coronary artery bypass graft surgery
  CAD
  coronary artery disease
  CCS
  Canadian Cardiovascular Society
  CO2
  carbon dioxide
  DIRECT
  Direct Myocardial Revascularization in Regeneration of Endomyocardial Channels trial
  DMR
  direct myocardial revascularization
  FDA
  Food and Drug Administration
  Ho:YAG
  holmium:yttrium-argon-garnet
  IABP
  intraaortic balloon pump
  MRI
  magnetic resonance imaging
  PCI
  percutaneous coronary intervention
  PET
  positron emission tomography
  PMR
  percutaneous myocardial laser revascularization
  SPECT
  single-photon emission computed tomography
  TEE
  transesophageal echocardiography
  TMR
  transmyocardial laser revascularization
  VEGF
  vascular endothelial growth factor




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