LASERS IN CARDIOVASCULAR MEDICINE AND SURGERY: FUNDAMENTALS
AND TECHNIQUES
Developments tn Cardiovascular Medicine
Reiber, J .H.C., Serruys, P. W., Slager, C.].: Quantitative coronary and left ventricular cineangiography. ISBN 0-89838-760-4. DICM 51
Fagard, R.H., Beksert, I.E., eds.: Sports cardiology. ISBN 0-89838-782-5. DICM 52 Reiber,J.H.C., Serruys, P.W., eds.: State of the art in quancitative coronary arteriography. ISBNO-89838-804-X. DICM 53 Roelandt, J., ed.: Color doppler flow imaging. ISBN 0-89838-806-6. DICM 54 van der Wall. E.E., ed.: Noninvasive imaging of cardiac metabolism. ISBN 0-89838-812-0. DICM 55 Liebman, J., Plonsey, R., Rudy, Y., eds.: Pediatric and fundamental electrocardiography. ISBN 0-89838-815-5. DICM 56 Higler, H., Hombach, V., eds.: Invasive cardiovascular therapy. ISBN 0-89838-818-X. DICM 57 Serruys, P. W., Meester, G. T., eds.: Coronary angioplasty: a controlled model for ischemia. ISBN 0-89838-819-8. DIeM 58 Tooke, J .E., Smaje, L.H., eds.: Clinical investigation of the microcirculation. ISBN 0-89838-833- 3. DICM 59 van Dam, Th., van Oosterom, A., eds.: Electrocardiographic body surface mapping. ISBN 0-89838-834-1. DICM 60 Spencer, M.P., ed.: Ultrasonic diagnosis of cerebrovascular disease. ISBN 0-89838-836-8. DICM 61 Legaro, M.]., ed.: The stressed heart. ISBN 0-89838-849-X. DICM 62 Safar, M.E., ed.: Arterial and venous systems in essential hypertension. ISBN 0-89838-857-0. DICM 63 Roelandt, J., ed.: Digital techniques in echocardiography. ISBN 0-89838-861-9. DICM 64 Dhalla, N.S., Singal, P.K., Beamish, R.E., eds.: Pathophysiology of heart disease. ISBN 0-89838-864-3. DICM 65 Dhalla, N.S., Pierce, G.N., Beamish, R.E., eds.: Heart function and metabolism. ISBN 0-89838-865-1. DICM 66 Dhalla, N.S., Innes, I.R., Beamish, R.E., eds.: Myocardial ischemia. ISNB 0-89838-866-X. DICM 67 Beamish, R.E., Panagia, V., Dhalla, N.S., eds.: Pharmacological aspects of heart disease. ISBN 0-89838-867 -8. DICM 68 Ter Keurs, H.E.D.]., Tyberg, J. V., eds.: Mechanics of the circulation. ISBN 0-89838-870-8. DICM 69 Sideman, S., Beyar, R., eds.: Activation metabolism and perfusion of the heart. ISBN 0-89838-871-6. DICM 70 Aliot, E., Lazzara, R., eds.: Ventricular tachycardias. ISBN 0-89838-881- 3. DICM 71 Schneeweiss, A., Schettler, G.: Cardiovascular drug therapy in the elderly. ISBN 0-89838-883-X. DICM 72 Chapman, J. V., Sgalambro, A., eds.: Basic concepts in doppler echocardiography. ISBN 0-89838-888-0. DICM 73 Chien, S., Dormandy, J., Ernst. E., Matrai, A., eds.: Clinical hemorheology. ISBN 0-89838-807 -4. DICM 74 Morgantoth, J., Moore, E. Neil, eds.: Congestive heart failure. ISBN 0-89838-955-0. DICM 75 Heintzen, P.H., Bursch, J.H., eds.: Progress in digital angiocardiography. ISBN 0-89838-965-8. DICM 77 Scheinman, M., ed.: Catheter ablation of cardiac arrhythmias. ISBN 0-89838-967 -4. DICM 78 Spaan, J.A.E., Bruschke, A. V.G., Gittenberger, A.C., eds.: Coronary circulation. ISBN 0-89838-978-X. DICM 79 Bayes de Luna, A., ed.: Therapeutics in cardiology. ISBN 0-89838-981-X. DICM 81 Visser, c., Kan, G., Meltzer, R., eds.: Echocardiography in coronary artery disease. ISBN 0-89838-979-8. DIeM 80 Singal, P.K., ed.: Oxygen radicals in the pathophysiology of heart disease. ISBN 0-89838-375-7. DICM 86 Iwata, H., Lombardini, J.B., Segawa, T., eds:: Taurine and the heart. ISBN 0-89838- -. DICM 93 Mirvis, D.M., ed.: Body surface electrocardiographic mapping. ISBN 0-89838-983 -6. DICM 82 Morganroth, J., Moore, E.N., eds.: Silent myocardial ischemia. ISBN 0-89838- 380-3. DICM 88
LASERS IN CARDIOV ASCULAR
MEDICINE AND SURGERY:
FUNDAMENTALS AND TECHNIQUES
Edited by
George S. Abela, M. D. UNIVERSITY OF FLORIDA GAINESVILLE, FLORIDA
Kluwer Academic Publishers
BOSTON DORDRECHT LONDON
DISTRIBUTORS
for North America:
Kluwer Academic Publishers 101 Philip Drive Assinippi Park
Norwell, Massachusetts 02061 USA
fur all other countries:
Kluwer Academic Publishers Group Distribution Centre Post Office Box 322
3300 AH Dordrecht, THE NETHERLANDS
Library of Congress Cataloging-in-Publication Data
Lasers in cardiovascular medicine and surgery: fundamentals and techniques 1 edited by George S. Abela.
p. cm.-(Developments in cardiovascular medicine, DICM 103) Includes bibliographical references. ISBN-13: 978-1-4612-8801-5 1. Cardiovascular system-Laser surgery. 2. Laser angioplasty.
I. Abela, George S. II. Series: Developments in cardiovascular medicine; v. 103.
(DNLM: 1. Cardiovascular Diseases-therapy. 2. Laser Surgery. 3. Lasers-therapeutic use. 4. Vascular Surgery. WI DE997VME v. 1031 WG 170 L3431
DE997VME v. 103/WG 170 L3431 RD598.35.L37L37 1990 617.4' 13059-dc20 DNLM/DLC for Library of Congress 89-19854
CIP
Copyright 1990 by Kluwer Academic Publishers Soffcover reprint of the hardcover 1 st edition 1990
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, mechanical,
photocopying, recording, or otherwise, without the prior written permission of the publisher, Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park,
Norwell, Massachusetts 02061.
ISBN-I3: 978-1-4612-8801-5 e-ISBN-13: 978-1-4613-1489-9 001: 10.1007/978-1-4613-1489-9
CONTENTS
Contributing Authors Vll
Preface Xl
George S. Abela
Foreword X111
C. Richard Conti
I. HISTORICAL BACKGROUND 1
1. The History and Development of the Medical Laser 3 Leon Goldman
2. Historical Background, Development, and Future Trends of Lasers in Cardiovascular Disease 9 George S. Abela
II. LASER PHYSICS IN MEDICAL APPLICATIONS 19
3. Laser Physics and its Relevance to Applications in Medicine 21 jimjohnson
4. Laser Sources for Angioplasty 31 Robert F. Bonner, Paul D. Smith, Louis G. Prevosti, Antonio Bartorelli, Yaron Almagor, and Martin B. Leon
5. The Excimer Laser-Tissue Interactions and Early Clinical Results 45 Frank W . Cross, and Timothy j. Bowker
6. Laser Physics and Thermal Properties 59 AI Welch, Martinj.C. van Gemert, and Wai-Fung Cheong
7. Thermal Analysis of Laser Ablation of Cardiovascular Tissue 73 Massoud Motamedi, Gerald L. LeCarpentier, jorgeH. Torres, andAJ. Welch
8. Light Distribution, Optical Properties, and Cardiovascular Tissues 93 Martinj.C. van Gernert, AI Welch, Steven L. jacques, Wai-Fung Cheong, and Willem M. Star
III. EXPERIMENTAL STUDIES: LASERTISSUE INTERACTION, PROTODYNAMIC THERAPY, SPECTROSCOPY, ELECTROPHYSIOLOGY 111
9. Immediate and Chronic Effects of Laser Angioplasty 113 George S. Abela
10. Photosensitizer-Enhanced Laser Angioplasty 143 G. Michael Vincent, George S. Abela and Enrico Barbieri
11. Laser-Induced Arterial Fluorescence Spectroscopy 153 Lawrence I. Decklebaum
12. Laser Balloon Angioplasty: Experimental In-Vivo and In-Vitro Studies 167 j. Richard Spears, I. Nigel Sinclair, and Ronald D.jenkins
13. Laser Catheter Ablation of Arrhythmias 189 AnneB. Curtis, G. Michael Vincent and George S. Abela
IV. LASER DELIVERY SYSTEMS 201
14. Optical Fibers 203 Stephan E. Friedl, Biqing Ye and George S. Abela
15. Laser Angioplasty with Optically Modified Fiber Tips 209 Cornelius Borst, Rudolf M. Verdaasdonk, and Rienk Rienks
v
VI CONTENTS
16. Catheter Systems for Laser Angioplasty 229 GeorgeS. Abela, andGeraldR. Barbeau
V. CLINICAL EXPERIENCE WITH LASER ANGIOPLASTY 255
17. Clinical Experience with Laser Angioplasty 257 Gerald R. Barbeau and George S. Abela
18. Laser Recanalization and Treatment of Peripheral Atherosclerosis: A Vascular Surgeon's Perspective 27 3 james M. SeegerandGeorgeS. Abela
19. Intraoperative Use of the Laser for Coronary Artery Disease 283 james]. Livesay
20. Laser Thermal Angioplasty with an Argon-Laser-Heated, Metallic-Capped Fiber optic 291 Timothy A. Sanborn
21. Laser Angioplasty Using a Special Sapphire-Tip Catheter: Preliminary Clinical Trial 301 j. Louis Fourier, and M. Bertrand
22. Laser Angioplasty: New Modalities 307 Herbert j. Geschwind
23. Evaluation, Treatment, and Care of the Laser Angioplasty Patient: A Nursing Perspective 315 Sharonjablonski
VI. ADDITIONAL CLINICAL EXPERIENCE WITH OTHER CARDIOVASCULAR LASER APPLICATIONS 325
24. Laser Modification of the Myocardium for the Treatment of Cardiac Arrhythmias: Background, Current Results, and Future Possibilities 327 Robert H. Svenson, Laszlo Littmann,john]. Gallagher, jay Selle, Samuel Zimmern, john Fedor, Marie-Claire Marroum, Kathleen Seifert, George P. Tatsis, and Kathy Linder
25. Laser Endarterectomy 347 john Eugene, Yvon Baribeau, and Michael W. Berns
26. Vascular Tissue Bonding Using Laser Energy 361 Rodney A. White, George Kopchok, and Geoffrey White
27. Percutaneous Laser Myoplasty for Treatment of Hypertrophic Cardiomyopathy 373 Dov Gal, Douglas Losordo, andjeffrey M. Isner
28. Direct Myocardial Revascularization: Preliminary Experience 385 Mahmood Mirhoseini and Mary M. Cayton
VII. ANGIOSCOPY AND ULTRASOUND GUIDANCE 397
29. Percutaneous Cardiovascular Angioscopy 399 Yasumi Uchida
30. Angioscopy of Congenital Cardiac Lesions 411 Michel Sargin
31. Intravascular Ultrasound Imaging 423 john A. Mallery, jonathan M. Tobis, james M. Gessert, james M. Griffith, Michael W. Berns, and Walter L. Henry
VIII. INDUSTRIAL, REGULATORY AND POPULATION ANALYSIS 437
32. Safety and Effectiveness in Clinical Trials Involving Lasers: Food and Drug Administration
33.
34.
Perspective 439 Richard P. Felten, and Lynne A. Reamer
Market Trends and Business Considerations 449 Stephen M. Fry
The Acceptance of Percutaneous Transluminal Angioplasty and Laser Angioplasty 459 john Abele
Glossary Index
465 469
CONTRIBUTING AUTHORS
George S. Abela, M.D. Associate Professor of Medicine Director, Cardiovascular Laser Laboratory Department of Medicine/Cardiology University of Florida Gainesville, FL 32610 USA
John E. Abele, Ph .D. Co-Chairman Boston Scientific Corporation 480 Pleasant St . Watertown, MA 02172 USA
Yaron Almagor, M.D. Research Fellow Cardiology Branch Heart, Lung and Blood Instituce NIH Building 10 Bethesda, MD 20892 USA
Gerald R. Barbeau, M.D. Associate Clinical Professor Institute De Cardiologie De Quebec 2725 Chemin Ste-Foy, Sainte-Foy Province de Quebec Canada
Enrico Barbieri, M.E. Fulbright Scholar Institute of Cardiology of the University of Verona Verona, Italy
Yvon Baribeau, M.D. 717 Bay St. #902 Toronto, Onrario M15G2J9, Canada
Antonio Bartorelli, M.D. Research Fellow Cardiology Branch NHLBI NIH Bethesda, MD 20892 USA
Michael W. Berns, M.D. Professor of Surgery Developmental & Cell Biology Director, Beckman Laser Institute University of California, Irvine 101 The City Drive Orange, CA 92668 USA
Michael E. Bertrand, M.D. Professor and Chief Service de Cardiologie B et Hemodynamic H6pital Cardiologique Centre Hospitalier Regional et Universitaire de Lille
Boulevard du Professor J . Leclercq 59037 Lille Cedex France
Robert F. Bonner, Ph.D. Physicist National Institutes of Health Electrical and Electronic Engineering of Biomedical Engineering and Instrumentation Branch Division of Research Service 9000 Rockville Pike Bldg. 13, Rm 3W13 Bethesda, MD 20892 USA
Cornelius Borst, M.D. Professor of Experimental Cardiology Academisch Ziekenhuis Utrecht Cathari j nesingel 3511 GV Utrecht The Netherlands
Timothy J. Bowker, MA Clinical Lecturer The Cardiothoracic Institute The Brompton Hospital Fulham Road London United Kingdom
Mary M. Cayton, R.N. Clinical Specialist Cardiovascular Surgery Clinical Specialist Laser Surgery St. Luke's Medical Center Heart and Lung Institute of Wisconsin Laser Research Laboratory Clement Zablocki Veterans Administration Medical Center Milwaukee, Wisconsin USA
Wai-Fung Cheong, Ph .D. Biomedical Engineering Program The University of Texas at Austin Austin, TX 78712 USA
Anne B. Curtis, M.D. Associate Professor Director of Electrophysiology BoxJ-277 JHMHC College of Medicine University of Florida Gainesville, Florida 32610 USA
Frank W . Cross, M.D. Senior Surgical Registrar 7 Millers Way Horsford Norwich, Norfolk NR 103 DV United Kingdom
Vll
V1l1 CONTRIBUTING AUTHORS
Lawrence 1. Decklebaum, M.D. Assistant Professor of Medicine Yale University School of Medicine Director, Cardiac Catheterization Lab West Spring Street West Haven, CT 06516 USA
John Eugene, M.D. Associate Professor of Surgery University of California, Irvine 23451 Madison Street, Ste. 160 Torrance, CA 90505 USA
John Fedor, M.D. Medical Director, Cardiac Rehabilitation Program Laser and Applied Technologies Laboratory Sanger Clinic 1960 Randolph Road Charlotte, NC 28232-2861 USA
Richard P. Felten Research Chemist Food and Drug Administration Center for Devices and Radiological Health 12709 Twinbrook Parkway Rockville, MD 20857 USA
Jean-Louis Fourrier, M.D. Chef de Clinique Universite de Lille Service de Cardiologique de Lille Boulevard du Professeur J. Leclerccq 59037 Lille Cedex France
Stephan E. Friedl, ME.E. Department of Medicine/Cardiology University of Florida BoxJ-277 JHMHC Gainesville, Florida 32610 USA
StephenM. Fry, Ph.D. President, Strategic Business Development, Inc. P.O. Box 1155 Hanalei Kauai, Hawaii 96714 USA
DovGal, D.V.M. St. Elizabeth's Hospital of Boston Departments of Biomedical Research and Medicine
(Cardiology) 736 Cambridge Street Boston, MA 02135 USA
JohnJ. Gallagher, M.D. Director, Electrophysiology Services, Lasers and Applied
Technologies Laboratory Sanger Clinic 1960 Randolph Road Charlotte, NC 28207 USA
Herbert 1. Geschwind, M.D. Director Cardiac Catheterization Laboratory
Service D' explorations Fonctionnelles Inserm U 138 C.H. U. Henri-Modor 51, Ave. Du Marechal De Lattre de
Tassigny 94010 Creteil France
James M. Gessert Display Systems Engineer InterTherapy, Inc. Costa Mesa, CA USA
James M. Griffith, Ph.D. Director, Research & Development InterTherapy, Inc Costa Mesa, CA USA
Leon Goldman, M.D. Professor Emeritus University of Cincinnati Laser Consultant Naval Hospital, San Diego 7811 Eads Ave. #304 LaJolla, CA 92037 USA
Walter 1. Henry, M.D. Professor of Medicine Vice Chancellor, Health Sciences and Dean, California College of Medicine University of California, Irvine USA
Jeffery Isner, M.D. Professor of Medicine and Pathology Tufts University School of Medicine Chief, Cardiovascular Research St. Elizabeth's Hospital of Boston 736 Cambridge Street Boston, MA02135 USA
Sharon Jablonski, RN Clinical Research Nurse 500-110 Ave. N., #506 St. Petersburg, FL 33716 USA
Stephen 1. Jacques, Ph.D. Wellman Laboratory of Photo medicine Department of Dermatology Massachusetts General Hospital Boston, MA 02114 USA
Ronald D. Jenkins, M.D. Fellow, Cardiology Division Charles A. Dana Research Institute and Harvard Thorndike Laboratory of Beth Israel Hospital Department of Medicine Cardiovascular Division Beth Israel Hospital Harvard Medical School Boston, MA 02115 USA
Jim Johnson, Ph.D. President, Photon Dynamics Ltd., Inc.
CONTRIBUTING AUTHORS
4722 Arrow Rd. Orlando, FL 32806 USA
George Kopchok, B.S. Harbor/UCLA Medical Center 1000 W. Carson Street Torrance, CA 90502 USA
GeraldL. LeCarpentier, M.S. Graduate Student University of Texas Engineering Science Building, Room 639 Austin, TX 78712
Martin B. Leon, M.D. Senior Investigator and Co-Director of the Cardiac
Catheterization Laboratory Cardiology Branch Heart, Lung and Blood Institute Building 10 Room 7315 Bethesda, MD 20892 USA
Kathy Linder, M.S. Laser and Applied Technologies Laboratory Sanger Clinic 1960 Randolph Road Charlotte, NC 28207 USA
Lazlo l.ittmann, M.D. Director of Electrophysiology Research Carolina Heart Institute P.O. Box 32861 Charlotte, NC 28232 USA
JamesJ. Livesay, M.D. Associate in Cardiovascular Surgery Texas Heart Institute and Attending Surgeon St. Lukes Episcopal Hospital Clinical Associate Professor of Surgery at Houston Houston, Texas 77225 USA
Douglas Losordo, M.D. Departments of Biomedical Research and Medicine
(Cardiology) 736 Cambridge Street Boston, MA02135 USA
JohnA. Mallery, M.D. Assistant Adjunct Professor of Medicine Acting Director, Coronary Care Unit Cardiology/Surgery Liaison University of California, Irvine USA
Marie-Clair Marroum, M.D. Laser and Applied Technologies Laboratory Sanger Clinic 1960 Randolph Road Charlotte, NC 28207 USA
Mahmood Mirhoseini, M.D. Assistant Clinical Professor
Cardiac Thoracic Surgery Medical College of Wisconsin Laser Research Laboratory 2722 W. Oklahoma Ave. Milwaukee, Wisconsin 53215 USA
Massoud Motamedi, Ph.D. Assistant Professor of Internal Medicine Wayne State University Engineering Director of the Cardiac Laser Program Louis Elliman Research Building 421 East Canfield St. Detroit, Michigan 48201 USA
Louis G. Prevosti, M.D. Research Associate National Institutes of Health 12900 Lake Ave. Suite 526 Lakewood, Ohio 44107
Lynne Reamer Division of Cardiovascular Devices Bureau of Medical Devices Food and Drug Administration 1390 Piccard Dr. Rockville, MD 20850 USA
Rienk Rienks, M.D. Academisch Ziekenhuis Utrecht Heart-Lung Institute Utrecht Department of Cardiology Room 62.002 Catharijnesingel 101 3511 GV Utrecht The Netherlands
Timoth A. Sanborn, M.D. Associate Professor of Medicine Mt. Sinai School of Medicine Director, Interventional Cardiology Research and Laser
Angioplasty Program Mt. Sinai Hospital 1 G. 1. Levy Place Box 1030 New York, NY 10029 USA
Mikhail Sargin, M.D. Senior Research Scientist Dept. of Cardiac Surgery A. V. Vishnevsky Institute of Surgery Serpukhovskaya 27 St. Moscow, USSR
James M. Seeger, M.D. Associate Professor of Medicine Chief, Vascular Surgery Veterans Administration Medical Center Box]-286 ]HMHC College of Medicine University of Florida Gainesville, Florida 32610 USA
IX
x CONTRIBUTING AUTHORS
Kathleen Seifert , M.S. Laser and Applied Technologies Laboratory Carolinas Heart Institute Post Office Box 32861 Charlotte, NC 28232 USA
Jay Selle, M.D. Chief, Vascular Surgical Service Department of Thoracic Cardiac and Vascular Surgery Laser and Applied Technologies Laboratory Sanger Clinic 1960 Randolph Road Charlotte, NC 28207 USA
I. Nigel Sinclair, M.D. Department of Medicine Cardiology Section The Sir Charles Gardner Hospital Perth, Australia
Paul D. Smith, Ph.D. Cardiology Branch Bldg. 13, Room 3W13 NIH Bethesda, MD 20892 USA
RichardJ. Spears, M.D. Associate Professor of Internal Medicine Wayne State University School of Medicine Director, Cardiac Laser Program Harper Hospital Louis Elliman Research Building 421 East Canfield Sf. Detroit, Michigan 48201 USA
Willem M. Star, Ph.D. Department of Clinical Physics Dr. Daniel den Hoed Cancer Centre Rotterdam The Netherlands
Robert H. Svenson, M.D. Medical Director, Laser Program Sanger Clinic 1960 Randolph Road Charlotte, NC 28207 USA
George P. Tatsis, B.S. Associate Director, Laser Porgram Laser and Applied Technologies Laboratory Carolinas Heart Institute Post Office Box 32861 Charlotte, NC 28232 USA
Jonathan M. Tobis, M.D. Associate Professor of Medicine Acting Chief, Division of Cardiology Director, Cardiac Catheterization Lab University of California, Irvine Medical Center Bldg. 53 101 City Drive S. Orange, CA 92668 USA
Jorge H. Torres, M.D. Graduate Student
University of Texas Engineering Science Building, Room 639 Austin, TX 78712
Yasumi Uchida, M.D. Associate Professor of Medicine Head Section Cardiology 2nd Division of Internal Medicine Ohno 3-1739-8 Ichikawa City Chiba Prefecture Japan
MartinJ.C. van Gernert, Ph.D. Head, Laser Center Academic Hospital at the University of Amsterdam Academic Medical Center Mei bergdreef 9 1105 AZ Amsterdam Zuidoost The Netherlands
RudolfM. Verdaasdonk, M.Sc. Heart-Lung Institute Department of Cardiology University Hospital Utrecht The Netherlands
G. Michael Vincent, M.D. Associate Professor of Medicine Chairman, Department of Medicine LOS Hospital 8th Avenue and C street Salt Lake City, UT 84143 USA
A. J . Welch, Ph.D. Marion E. Forsman Centennial Professor Professor, Electronic Computer and Biomedical
Engineering University of Texas Engineering Science Building, Room 639
Rodney A. White, M.D. Associate Professor of Surgery Chief, Vascular Surgery Harbor/UCLA Medical Center 1000 W. Carson St. Torrance, CA 90502 USA
Geoffrey H. White, M.D. Assistant Professor of Surgery Harbor/UCLA Medical Center 1000 W . Carson St. Torrance, CA 90502 USA
Biqing Ye Associate Professor Shanghai Institute of Optics and Fine Mechanics Chinese Academy of Sciences P.O. Box 8211 Shanghai, P.R. China
Samuel Zimmern, M.D. Director Pacemaker Program Sanger Clinic 1960 Randolph Road Charlotte, NC 28207 USA
PREFACE
Following the advent of percutaneous balloon angioplasty, interventional cardiovascular procedures have become of great interest to the cardiologist, radiologist, and cardiovascular surgeon. One of the most extensively explored alternatives to bypass surgery is laser-mediated angioplasty. The fascination with laser radiation has greatly contributed to its popularity, but has also burdened it with unrealistic expectations. Many commercial laser systems are available to the clinician and the researcher, which often makes the choice of a laser system difficult and confusing. Also the method of using these systems often seems to be ambiguous, and patient selection and lesion choice for treatment are not well defined.
This book attempts to describe the most upto-date technology and procedural approaches of laser angioplasty using the various laser systems. In order to accomplish this, several sections have been developed to address these specific issues. A group of nationally and internationally recognized authors have contributed to this book to provide the widest possible experience in the field.
Part I (Chapters 1-2) provides a historical background and future projection for lasers in the cardiovascular field.
Part II serves as an introduction to lasers, with a description of the various types and functions. This basic science background has several chapters (3 - 5) oriented for the beginner in the field. Chapters 6-8 provide a more advanced discussion for researchers who are involved in the basic science of laser-tissue interaction.
Part III (Chapters 9-13) summarizes the experimental work done in laser angioplasty. This includes the immediate and chronic effects on arterial tissue, plaque photosensitization for enhanced ablation as well as fluorescence characteristics for plaque detection. Also experimental results of the laser balloon angioplasty and use of the laser for His-bundle ablation are discussed.
Part IV (Chapters 14-16) describes the various fibers and catheter systems that have been de-
vel oped and are available for clinical use, as well as those that are still in investigational phases. Clinical case reports are presented by expert investigators on the use of various catheter systems in the coronary and peripheral circulation.
Part V (Chapters 17-23) is the most up-todate review of the clinical experience with various laser delivery systems. There is an emphasis on patient selection, criteria for lesion choice, and follow-up data. A detailed description of laser recanalization techniques is presented for the various systems in the clinical setting. Chapters 17, 20, 21, and 22, describe percutaneous laser angioplasty techniques, while Chapters 18 and 19 describe intraoperative surgical applications. Chapter 23 provides a unique experience on the nursing care, management, screening and follow-up of the lasertreated patient.
Part VI (Chapters 24-28) describes other possible applications of lasers in the cardiovascular area. Clinical experience in electrophysiology for arrhythmia foci ablation is presented; also specific surgical applications such as endarterectomy, and arterial welding are described. Myocardial effects are evaluated for the treatment of cardiomyopathy. Also, a more futuristic concept is explored, in which direct myocardial revascularization is used to treat ischemia in areas that are potentially viable but without vascular of perfusion.
Part VII (Chapters 29- 31) discusses the use of angioscopy and ultrasound for diagnosis of atherosclerotic and thrombotic occlusions illustrated by color plates during acute myocardial infarction. Both these techniques can be used as a method to guide laser angioplasty. Additionall y, special applications of angioscopy for the evaluation of congenital heart disease are presented.
Part VIII (Chapters 32- 34) describes the impact of laser technology on the medical community with respect to safety considerations and future trends. A closing chapter describes the historical evolution of the field of interventional cardiovascular instrumentation.
An attempt is made in this book to address
XI
Xli PREFACE
inrerests of various specialists involved in the use of laser technology. These include primarily the cardiovascular physician and researcher. Also, attention is given to nurses who are involved in the care and management of patients undergoing cardiovascular laser treatment.
A final message is to emphasize safety. Analysis of the future direction of this field is provided for individuals interested in the longterm viability of laser technology and its applications. After reading this book, one should
have a better understanding of lasers and a clearer view of how and when laser devices can be used safely in the cardiovascular system.
Great thanks is due to the contributors of this book as much of the work presented is original. It is the earnest dedication of these physicians, scientists, and engineers that has brought a simple idea to reality.
George S. Abela Editor
FOREWORD
I have been asked by Dr. Abela to write an introduction to Lasers in Cardiovascular Medicine and Surgery. Dr. Abela is a personal friend of mine and a fellow member of the Division of Cardiology at the University of Florida College of Medicine. Thus, I have been able to observe at close range his progress in the area of laser research for the past 9 years.
In 1980 Dr. Abela, then a Fellow in Cardiology at the University of Florida, approached me about the possibility of using the laser to recanalize vascular obstructions. At that time, nonsurgical revascularization of ischemic myocardium was a reality because balloon coronary angioplasty and intracoronary streptokinase administration had been performed successfully in many patients. In this milieu, Dr. Abela and a few others were stimulated to search for other possible techniques to clear intravascular obstructions. Over the years, many clinicians have become interested in the use of the laser to treat cardiovascular and peripheral vascular disease. Many of those individuals are authoring chapters in this textbook.
Some of the early workers in this field include Ginsburg and associates at Stanford, who recanalized a femoral arterial occlusion using the argon laser; Geschwind and colleagues in France, who reduced a vascular stenosis in the peripheral circulation; Choy and coworkers, who successfully recanalized five occluded coronary arteries at the time of bypass surgery; and Livesay and colleagues at the Texas Heart Institute, who recanalized 16 coronary arteries using a handheld CO2 "gun" at the time of coronary artery surgery. During the time that these preliminary experiences were being reported, numerous investigations were taking place in animal models of vascular obstruction.
More recently, Cumberland, Abela, and others have performed revascularization procedures in the peripheral circulation using the laser and adjunctive balloon angioplasty, when necessary. Thus, the field has moved rather rapidly from in-vitro and in-vivo experiments in animals, to a few experiments in humans, to clinically applicable use of the laser, to re-
canalization of vascular obstructions in the peripheral circulation of humans.
Other potential applications for the use of laser energy in patients with cardiovascular disease include HIS-bundle and arrhythmia focus ablation in patients with uncontrolled arrhythmias, septal myectomy in patients with hypertrophic cardiomyopathy, creation of therapeutic shunts such as an ASD in patients with heart disease requiring mixing, recanalization of therapeutic shunts that have thrombosed (e.g., Blalock-Taussig shunts), and relief of valve obstruction. However, much work is needed to improve these methods from a technical standpoint. Three potential problems exist: thrombosis, embolization, and perforation of the vessel or the myocardium. From studies in animals, it seems unlikely that thrombosis will be a problem. Healing occurs normally, as does reendothelialization of a blood-vessel wall. Distal embolization may occur, but this problem is unlikely to be serious. In contrast, perforation still remains an important problem, especially if a technique using the percutaneous approach is used in the coronary circulation. In the peripheral circulation, perforation of an artery, although serious, would not be as life threatening as coronary artery perforation, from which pericardial tamponade can result with catastrophic consequences.
In my view, to minimize the problem of perforation, effort must be made to 1) develop new methods to control the position of the optical fiber within the blood vessel, 2) define the energy ranges required to vaporize plaques, 3) control the direction of the emitted laser beam more precisely, and 4) possibly develop photosensitizing agents that localize plaque and decrease energy requirements for plaque ablation.
The development of laser techniques should be similar to that of balloon angioplasty, i. e., a careful, stepwise approach in which investigators study effects and gather experience by using the technique in the peripheral circulation. When this information has been obtained, reported, and confirmed, other vascular beds can be studied. Time will allow investigators to
XIII
XIV FOREWORD
understand the potential hazards of the technique and to gain confidence.
I remain optimistic that the laser will reach its full potential and be applicable to the coronary circulation of humans. While I doubt that it will replace balloon angioplasty or coronary artery bypass surgery, I believe it will be an adjunct to these well-established procedures.
C. Richard Conti, M.D. Palm Beach-Martin Co. Heart Assoc. Eminent Scholar (Cardiology) Professor of Medicine Director, Division of Cardiovascular Medicine University of Florida Gainesville, Florida
ACKNOWLEDGMENT
This book would have never made the deadline without the help of the following people. Thanks to Gerald R. Barbeau, Fellow in cardiology, for his patient review of many of the chapters; to
Stephan E. Friedl, Scientist-Engineer, for pre-
paration of the glossary; to Cindy Jordan and Cindy Puckett, for their expert typing skills; and to Christine R. Finnegan, for editing and proofing the manuscript.
Dedication
I would like to dedicate this work to my wife Sonia, to Albert Abela and
to my aunt Nelly without whose support and patience this work could not have been done. I would also like
to thank my teachers and my colleagues, whose contributions have
made this work possible.
George S. Abela