Extent of myocardial collateralization: determination with three-dimensional elastic-subtraction spiral CT

Angiogenesis: Bench to Bedside, Have We Learned Anything?

End-stage ischemic cardiomyopathy patients are an ever-increasing group of coronary artery disease patients, often with no options in our current treatment armamentarium. Angiogenesis therapy pre-clinical and phase I clinical trials showed great promise, however, the benefits of single growth factor treatments have not been borne out in the larger phase II randomized trials. The complexity of angiogenesis process and the challenges in creating animal models to replicate and study this process in ischemic adult human myocardium have been major limitations to progress in this field. In addition failure to control for the powerful placebo effect in the clinical trials and inadequate methods of outcomes measures assessment have created difficult to overcome road blocks in establishing the efficacy of angiogenic strategies. Herein we review the challenges of angiogenesis research and development of treatment strategies. We also propose a structured model for further investigations of angiogenic therapies. The adherence to such a regimented approach as proposed here is, in our opinion, the only way to achieve success in angiogenesis approach development to treatment of patients with end-stage cardiac ischemia refractory to other established therapies.

Imaging myocardial angiogenesis

Imaging myocardial angiogenesis presents a major technical challenge because the ideal spatial resolution required is substantially higher than that available with standard X-ray angiography and nuclear medicine imaging. Moreover, these clinical imaging methods are currently inadequate (because of insufficient resolution) for clinical trials of angiogenic agents for the treatment of ischemic heart disease. Specialized techniques in MRI, ultrasonography, echocardiography and CT that are under development might provide improved means of imaging myocardial angiogenesis. Molecular imaging technologies are also being developed to improve resolution and to provide a better mechanistic insight into angiogenic therapies for ischemic heart diseases. This Review examines advanced methods for imaging angiogenesis. These technologies might soon permit data to be obtained directly from scientific studies and clinical trials.

Magnetic resonance imaging demonstrates improved regional systolic wall motion and thickening and myocardial perfusion of myocardial territories treated by laser myocardial revascularization

OBJECTIVES

This study was designed to investigate the use of magnetic resonance (MR) functional and perfusion imaging to evaluate laser myocardial revascularization (LMR).

BACKGROUND

Most clinical studies of LMR have shown improvements in angina class and exercise capacity, with minimal or absent improvements in myocardial perfusion and function.

METHODS

Fifteen patients who underwent percutaneous Biosense-guided holmium:yttrium aluminum garnet LMR to areas of viable but ischemic myocardium were followed clinically and underwent functional and perfusion MRI at baseline, 30 days and 6 months.

RESULTS

The mean age was 64 +/- 11 years; four patients were women. The ejection fraction was 47.4 +/- 14.0%. Angina class at baseline was 3.4 +/- 0.6 and improved to 2.5 +/- 1.4 at six months (p = 0.054). Exercise time at baseline was 298 +/- 97 s and increased to 350 +/- 95 s at 30 days and 365 +/- 79 s at six months, p = 0.04. There were no significant changes in nuclear perfusion scans. Although MR determined that resting radial motion and thickening of the target wall were significantly less than normal at baseline (p < 0.001), they improved significantly during follow-up (wall thickening: baseline, 30.6 +/- 11.7%; day 30, 41.2 +/- 13.3% and day 180, 44.2 +/- 11.9%, p = 0.01). The size of the underperfused myocardial area was 14.5 +/- 5.4% at baseline and was reduced to 6.3 +/- 2.8% at 30 days and 7.7 +/- 3.7% at 6 months (p < 0.001).

CONCLUSIONS

This small phase I, open-label, uncontrolled study of MR functional and perfusion imaging in patients undergoing Biosense-guided LMR suggests a beneficial effect of this treatment strategy on myocardial function and perfusion. The efficacy of Biosense-guided LMR is being evaluated in a large phase II, randomized, blinded placebo-controlled trial with an MRI substudy (DIRECT).

Coronary angiogenesis: detection in vivo with MR imaging sensitive to collateral neocirculation--preliminary study in pigs

PURPOSE

To assess the ability to track neovascularization over time with a magnetic resonance (MR) imaging technique sensitized to new intramyocardial collateral development as a means of evaluating therapeutic angiogenesis.

MATERIALS AND METHODS

Magnetization preparation plus spatial frequency reordering was applied to distinguish new intramyocardial collateral vessels from normal circulation on the basis of geometric differences. A vascular occluder was inserted in 34 pigs, and they were assigned randomly to treatment groups with either placebo or angiogenic growth factor. Collateral extent determined with collateral-sensitive MR imaging was correlated with direct measurements by means of three-dimensional (3D) computed tomography (CT), coronary blood flow distribution determined with microspheres, and findings at histologic examination. Changes in the signal at collateral-sensitive MR imaging before and after treatment were assessed by two observers blinded to treatment.

RESULTS

The collateral extent determined with collateral-sensitive MR imaging correlated well with findings at 3D CT (r = 0.95) and with microspheres (r = 0.86). Furthermore, the collateral extent determined with collateral-sensitive MR imaging increased significantly (P < .001) in response to the administration of an angiogenic growth factor but not to placebo. The correspondence of findings at collateral-sensitive MR imaging to collateral neovascularization was confirmed at histologic examination.

CONCLUSION

The presence of intramyocardial collateral microvessels was accurately determined with collateral-sensitive MR imaging. The technique may be useful in clinical studies of therapeutic angiogenesis.

Therapeutic myocardial angiogenesis using percutaneous intrapericardial drug delivery

In this manuscript, we describe the potential role of the pericardial space as a drug delivery reservoir to administer angiogenic agents to the heart resulting in functionally significant angiogenesis with single bolus basic fibroblast growth factor (bFGF) delivery. We also describe a percutaneous subxyphoid pericardial access technique that is safe, rapid, and reliable.