Laser induced fluorescence identification of sinoatrial and atrioventricular nodal conduction tissue

Toward detection of conduction tissue during cardiac surgery: Light at the end of the tunnel?

Postoperative conduction block requiring lifetime pacemaker placement continues to be a considerable source of morbidity for patients undergoing repair of congenital heart defects. Damage to the cardiac conduction system (CCS) during surgical procedures is thought to be a major cause of conduction block. Intraoperative identification and avoidance of the CCS is thus a key strategy to improve surgical outcomes. A number of approaches have been developed to avoid conduction tissue damage and mitigate morbidity. Here we review the historical and contemporary approaches for identification of conduction tissue during cardiac surgery. The established approach for intraoperative identification is based on anatomic landmarks established in extensive histologic studies of normal and diseased heart. We focus on landmarks to identify the sinus and atrioventricular nodes during cardiac surgery. We also review technologies explored for intraoperative tissue identification, including electrical impedance measurements and electrocardiography. We describe new optical approaches, in particular, and optical spectroscopy and fiberoptic confocal microscopy (FCM) for identification of CCS regions and working myocardium during surgery. As a template for translation of future technology developments, we describe research and regulatory pathways to translate FCM for cardiac surgery. We suggest that along with more robust approaches to surgeon training, including awareness of fundamental anatomic studies, optical approaches such as FCM show promise in aiding surgeons with repairs of heart defects. In particular, for complex defects, these approaches can complement landmark-based identification of conduction tissue and thus help to avoid injury to the CCS due to surgical procedures.

Visualization of human heart conduction system by means of fluorescence spectroscopy

The conduction system of the heart is a specific muscular tissue, where a heartbeat signal originates and initiates the depolarization of the ventricles. The muscular origin makes it complicated to distinguish the conduction system from the surrounding tissues. A surgical intervention can lead to the accidental harm of the conduction system, which may eventually result in a dangerous obstruction of the heart functionality. Therefore, there is an immense necessity for developing a helpful method to visualize the conduction system during the operation time. The specimens for the spectroscopic studies were taken from nine diverse human hearts. The localization of distinct types of the tissue was preliminary marked by the pathologist and approved histologically after the spectral measurements. Variations in intensity, as well as in shape, were detected in autofluorescence spectra of different heart tissues. The most distinct differences were observed between the heart conduction system and the surrounding tissues under 330 and 380 nm excitation. The spectral region around 460 nm appeared to be the most suitable for an unambiguous differentiation of the human conduction system avoiding the absorption peak of blood. The visualization method, based on the intensity ratios calculated for two excitation wavelengths, was also demonstrated.

Spectroscopic studies of the human heart conduction system ex vivo: implication for optical visualization

Fluorescence excitation and emission spectra of the heart tissues specimens have been measured ex vivo with the aim of finding out the optical differences characteristic for the human heart conduction system (the His bundle) and ventricular myocardium. The optimal conditions enhancing the spectral differences between the His bundle and myocardium were found by recording the fluorescence signal in the range from 420 nm to 465 nm under the excitation at wavelengths starting from 320 nm to 370 nm. In addition, the spectral differences between the His bundle and the connective tissue, which is often present in the heart, could be displayed by comparing the ratios of fluorescence intensities being measured at above 460 nm under the preferred excitation of elastin and collagen. The left and right branches of the His bundle were visualized ex vivo in the interventricular septum of the human heart under illumination at 366 nm.

The role of laser-induced fluorescence in myocardial tissue characterization: an experimental in vitro study

OBJECTIVE

The fluorescence of tissue when stimulated by a laser beam is a well-known phenomenon. The resulting emission spectra depend on the biochemical and structural composition of the tissue. In this study, we examined the spectra of laser-induced fluorescence emitted by myocardial tissue.

METHODS

We used an argon-ion laser to stimulate the myocardium of 20 intact sheep hearts. For each spectral emission, we calculated the intensity in specific regions in order to characterize the spectra and to reveal intercavitary and intracavitary morphologic differences.

RESULTS

The statistical analysis showed significant differences in the emission spectra intensity between atria and ventricles. The intensity was higher in the atria than in the ventricles (p < 0.001). The atrial emission spectra were morphologically different from those of the ventricles. There was no difference in the intensity or morphology of emission spectra within each chamber. All measurements showed good reproducibility after a short period of time.

CONCLUSIONS

Laser-induced fluorescence of myocardial tissue seems to have the characteristics necessary for tissue recognition. This might prove useful in identifying cardiomyopathies and transplant rejection, as well as for myocardial mapping, assisting electrophysiologists in discovering fibrotic arrhythmogenic foci.

Detection of transplant vasculopathy in a rat aortic allograft model by fluorescence spectroscopic optical analysis

BACKGROUND AND OBJECTIVE

Transplant vasculopathy is a leading cause of late cardiac graft loss. We have examined laser-induced fluorescence (LIF) spectroscopy as an optical diagnostic tool for detection of intimal plaque development and inflammatory cellular invasion in a rat model of aortic allograft transplant.

STUDY DESIGN/MATERIALS AND METHODS

Infrarenal aortic segments were transplanted from Lewis to Sprague Dawley rats. A range of vasculopathy development was produced by treatment with a viral anti-inflammatory protein. LIF spectra were recorded from the intima of aortic implants at 28 days. Fluorescence intensity was analyzed for correlation with vasculopathy development.

RESULTS

Significant differences in LIF intensity at 400-450 nm (P < or = 0.05 by ANOVA) were detected. LIF emission was correlated with plaque growth (R2 = 0.980), vessel narrowing (R2 = 0.964), and cellular invasion (R2 = 0.971) by regression analysis.

CONCLUSION

LIF optical analysis provides a nontraumatic diagnostic approach for detection of atherosclerosis prior to cardiac transplant or during development of vasculopathy after transplant.

New method for detection of heart allograft rejection: validation of sensitivity and reliability in a rat heterotopic allograft model

BACKGROUND

Patients with inflammatory heart muscle diseases would benefit from a safe, convenient, rapidly performed diagnostic technique with real-time results not involving tissue removal. We have performed a detailed evaluation of detection of heart allograft rejection by autofluorescence in a heterotopic abdominal rat heart allograft model ex vivo.

METHODS AND RESULTS

Recipient rats with allograft (Lewis to Fisher 344; n=71) and isograft (Lewis to Lewis; n=33) hearts, treated with cyclosporine or untreated, were killed at days 2, 4, 7, 14, 21, 28, and 56 after transplant. Nontransplant controls with (n=24) or without (n=24) immunosuppressive therapy were also studied. When the rats were killed, autofluorescence spectra were acquired under blue-light excitation from midtransverse ventricular sections of native and transplanted hearts. Corresponding sections were then evaluated pathologically by a modified International Society for Heart and Lung Transplantation (ISHLT) grading schema. The spectral differences between rejecting and nonrejecting hearts were quantified by linear discriminant functions, producing scores that decreased progressively with increasing severity of tissue rejection. Mean+/-SD discriminant function scores were 2.9+/-1.6, 1.8+/-2.2, -0.1+/-2.8, -1.2+/-2.3, and -2.3+/-3.0 for isografts and allograft ISHLT grades 0, I, II, and III, respectively (Spearman rank-order correlation -0.6; P<0.001, test for trend). Cyclosporine had no detectable effect on the spectra.

CONCLUSIONS

The correlation between changes in autofluorescence spectra and ISHLT rejection grade strongly supports the possibility of catheter-based, fluorescence-guided surveillance of rejection.

Near infrared diffuse reflection and laser-induced fluorescence spectroscopy for myocardial tissue characterisation

In order to evaluate the potential of cardiovascular tissue characterisation using near-infrared (NIR) spectroscopy, spectra in a previously unexplored wavelength region 0.8-2.3 micron were recorded from various pig heart tissue samples in vitro: normal myocardium (with and without endo/epicardium), aorta, fatty and fibrous heart tissue. The spectra were analysed with principal component analysis (PCA), revealing several spectroscopically characteristic features enabling tissue classification. Several of the identified spectral features could be attributed to specific tissue constituents by comparing the tissue signals with spectra obtained from water, elastin, collagen and cholesterol as well as with published data. The results obtained with the NIR spectroscopy technique in terms of its potential to classify different tissue types were compared with those from laser-induced fluorescence (LIF) using 337 nm excitation. LIF and NIR spectroscopy can in combination with PCA be used to discriminate between all previously mentioned tissue groups, apart from fatty versus fibrous tissue (LIF) and aorta versus fibrous tissue (NIR), respectively. The NIR analysis was improved by focusing the PCA to the wavelength segment 2.0-2.3 microns, resulting in successful spectral characterisation of all cardiovascular tissue groups.

Ultraviolet and visible spectroscopies for tissue diagnostics: fluorescence spectroscopy and elastic-scattering spectroscopy

We review the application of fluorescence spectroscopy and elastic-scattering spectroscopy, over the ultraviolet-to-visible wavelength range, to minimally invasive medical diagnostics. The promises and hopes, as well as the difficulties, of these developing techniques are discussed.

In vivo fluorescence imaging for tissue diagnostics

Non-invasive fluorescence imaging has the potential to provide in vivo diagnostic information for many clinical specialties. Techniques have been developed over the years for simple ocular observations following UV excitation to sophisticated spectroscopic imaging using advanced equipment. Much of the impetus for research on fluorescence imaging for tissue diagnostics has come from parallel developments in photodynamic therapy of malignant lesions with fluorescent photosensitizers. However, the fluorescence of endogenous molecules (tissue autofluorescence) also plays an important role in most applications. In this paper, the possibilities of imaging tissues using fluorescence spectroscopy as a mean of tissue characterization are discussed. The various imaging techniques for extracting diagnostic information suggested in the literature are reviewed. The development of exogenous fluorophores for this purpose is also presented. Finally, the present status of clinical evaluation and future directions are discussed.

Laser-induced fluorescence: III. Quantitative analysis of atherosclerotic plaque content

BACKGROUND AND OBJECTIVE

Laser-induced fluorescence (LF) spectroscopic analysis of the chemical composition of atherosclerotic plaque was examined.

STUDY DESIGN/MATERIALS AND METHODS

The intima of 18 dog aortas was injected with chemical compounds found in atherosclerotic plaque. Spectra were recorded in air prior to and after injection of collagens I, III and IV, elastin, cholesterol, triglyceride, and beta-nicotinamide adenine dinucleotide (NADH).

RESULTS

Significant changes in LF intensity were detected after injection of collagens I and III, cholesterol and elastin in thoracic aorta (P < 0.001), but not with triglyceride or NADH. Minor changes were detected in abdominal aorta. Multiple regression analysis of LF intensity ratios demonstrated a clear correlation with the quantity of injected collagens I (R2 = 0.90-0.99) and III (R2 = 0.84-1.0), cholesterol (R2 = 0.72-0.76), and triglyceride (R2 = 0.68-0.80) in both thoracic and abdominal aorta. The correlation between LF and atherosclerotic plaque composition was confirmed in a rooster model of atherosclerosis where multiple regression analysis predicted the measured aortic cholesterol (R2 = 0.78) and triglyceride content (R2 = 0.96).

CONCLUSIONS

(1) Fluorescence spectra recorded from dog aorta were significantly altered by injection of collagens I and III, cholesterol, and elastin. (2) LF may allow quantitative assessment of plaque chemical content.