Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis

OBJECTIVE

To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted.

METHODS

MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data.

RESULTS

Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively.

CONCLUSIONS

The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Outcome of twin-twin transfusion syndrome according to Quintero stage of disease: systematic review and meta-analysis

OBJECTIVES

To report the outcome of pregnancies complicated by twin-twin transfusion syndrome (TTTS) according to Quintero stage.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I-V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage-I TTTS. Only cases treated with laser therapy were considered for those with Stages-II-IV TTTS and only cases managed expectantly were considered for those with Stage-V TTTS. Random-effects head-to-head meta-analysis was used to analyze the extracted data.

RESULTS

Twenty-six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage-I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0-89.7%) (456/552) of pregnancies with Stage-I, in 85% (95% CI, 79.1-90.1%) (514/590) of those with Stage-II, in 81.5% (95% CI, 76.6-86.0%) (875/1040) of those with Stage-III, in 82.8% (95% CI, 73.6-90.4%) (172/205) of those with Stage-IV and in 54.6% (95% CI, 24.8-82.6%) (5/9) of those with Stage-V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4-15.8%) (69/564) in those with Stage-I, 15.0% (95% CI, 9.9-20.9%) (76/590) in those with Stage-II, 18.6% (95% CI, 14.2-23.4%) (165/1040) in those with Stage-III, 17.2% (95% CI, 9.6-26.4%) (33/205) in those with Stage-IV and in 45.4% (95% CI, 17.4-75.2%) (4/9) in those with Stage-V TTTS. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage-I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4-95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6-90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2-97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0-77.9%) (73/108), 69.7% (95% CI, 61.6-77.1%) (203/285) and 80.8% (95% CI, 62.0-94.2%) (49/60), respectively.

CONCLUSIONS

Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage-III or -IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS treated with laser and expectant management, respectively. In pregnancies affected by Stage-I TTTS, amnioreduction was associated with slightly higher survival compared with laser therapy and expectant management, although these findings may be confirmed only by future head-to-head randomized trials. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients

BACKGROUND

Laser ablation (LA) is used as an upfront treatment in patients with deep seated newly diagnosed Glioblastoma (nGBM).

OBJECTIVE

To evaluate the outcomes of LA in patients with nGBM and compare them with a matched biopsy-only cohort.

METHODS

Twenty-four nGBM patients underwent upfront LA at Cleveland clinic, Washington University in St. Louis, and Yale University (6/2011-12/2014) followed by chemo/radiotherapy. Also, 24 out of 171 nGBM patients with biopsy followed by chemo/radiotherapy were matched based on age (< 70 vs ≥ 70), gender, tumor location (deep vs lobar), and volume (<11 cc vs ≥11 cc). Progression-free survival (PFS), overall survival (OS), and disease-specific PFS and OS were outcome measures. Three prognostic groups were identified based on extent of tumor ablation by thermal-damage-threshold (TDT)-lines.

RESULTS

The median tumor volume in LA (n = 24) and biopsy only (n = 24) groups was 9.3 cm3 and 8.2 cm3 respectively. Overall, median estimate of OS and PFS in LA cohort was 14.4 and 4.3 mo compared to 15.8 mo and 5.9 mo for biopsy only cohort. On multivariate analysis, favorable TDT-line prognostic groups were associated with lower incidence of disease specific death (P = .03) and progression (P = .05) compared to other groups including biopsy only cohort. Only age (<70 yr, P = .02) and tumor volume (<11 cc, P = .03) were favorable prognostic factors for OS.

CONCLUSION

The maximum tumor coverage by LA followed by radiation/chemotherapy is an effective treatment modality in patients with nGBM, compared to biopsy only cohort. The TDT-line prognostic groups were independent predictor of disease specific death and progression after LA.

Type II and III Selective Fetal Growth Restriction: Perinatal Outcomes of Expectant Management and Laser Ablation of Placental Vessels

OBJECTIVES

To describe the perinatal outcomes of type II and III selective fetal growth restriction (sFGR) in monochorionic-diamniotic (MCDA) twin pregnancies treated with expectant management or laser ablation of placental vessels (LAPV).

METHODS

Retrospective analysis of cases of sFGR that received expectant management (type II, n=6; type III, n=22) or LAPV (type II, n=30; type III, n=9). The main outcomes were gestational age at delivery and survival rate.

RESULTS

The smaller fetus presented an absent/reversed "a" wave in the ductus venosus (arAWDV) in all LAPV cases, while none of the expectant management cases presented arAWDV. The median gestational age at delivery was within the 32nd week for expectant management (type II and III) and for type II LAPV, and the 30th week for type III LAPV. The rate of at least one twin alive at hospital discharge was 83.3% and 90.9% for expectant management type II and III, respectively, and 90% and 77.8% for LAPV type II and III, respectively.

CONCLUSION

LAPV in type II and III sFGR twins with arAWDV in the smaller fetus seems to yield outcomes similar to those of less severe cases that received expectant management.

Management of people with early- or very early-stage hepatocellular carcinoma: an attempted network meta-analysis

BACKGROUND

Hepatocellular carcinoma (primary liver cancer) is classified in many ways. The Barcelona Clinic Liver Cancer (BCLC) group staging classifies the cancer based on patient's life expectancy. People with very early- or early-stage hepatocellular carcinoma have single tumour or three tumours of maximum diameter of 3 cm or less, Child-Pugh status A to B, and performance status 0 (fully functional). Management of hepatocellular carcinoma is uncertain.

OBJECTIVES

To assess the comparative benefits and harms of different interventions used in the treatment of early or very early hepatocellular carcinoma through a network meta-analysis and to generate rankings of the available interventions according to their safety and efficacy. However, it was not possible to assess whether the potential effect modifiers were similar across different comparisons. Therefore, we did not perform the network meta-analysis and instead assessed the benefits and harms of different interventions versus each other or versus sham or no intervention using standard Cochrane methodology.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and trials registers to September 2016 to identify randomised clinical trials (RCTs) on hepatocellular carcinoma.

SELECTION CRITERIA

We included only RCTs, irrespective of language, blinding, or publication status, in participants with very early- or early-stage hepatocellular carcinoma, irrespective of the presence of cirrhosis, portal hypertension, aetiology of hepatocellular carcinoma, size and number of the tumours, and future remnant liver volume. We excluded trials including participants who were previously liver transplanted. We considered interventions compared with each other, sham, or no intervention.

DATA COLLECTION AND ANALYSIS

We calculated the odds ratio, mean difference, rate ratio, or hazard ratio with 95% confidence intervals using both fixed-effect and random-effects models based on available-participant analysis with Review Manager 5. We assessed the risk of bias according to Cochrane, controlled risk of random errors with Trial Sequential Analysis using Stata, and the quality of the evidence using GRADE.

MAIN RESULTS

Eighteen trials met the inclusion criteria for this review. Four trials (593 participants; 574 participants included for one or more analyses) compared surgery versus radiofrequency ablation in people with early hepatocellular carcinoma, eligible to undergo surgery. Fourteen trials (2533 participants; 2494 participants included for various analyses) compared different non-surgical interventions in people with early hepatocellular carcinoma, not eligible to undergo surgery. Overall, the quality of evidence was low or very low for all outcomes for both comparisons. Surgery versus radiofrequency ablationThe majority of participants had cirrhotic livers, and the hepatocellular carcinoma was of viral aetiology. The trials did not report the participants' portal hypertension status or whether they received adjuvant antiviral treatment or adjuvant immunotherapy. The average follow-up ranged from 29 months to 42 months (3 trials).There was no evidence of a difference in all-cause mortality at maximal follow-up for surgery versus radiofrequency ablation (hazard ratio 0.80, 95% confidence interval (CI) 0.60 to 1.08; 574 participants; 4 trials; I² = 68). Cancer-related mortality was lower in the surgery group (20/115 (17.4%)) than in the radiofrequency ablation group (43/115 (37.4%)) (odds ratio 0.35, 95% CI 0.19 to 0.65; 230 participants; 1 trial). Serious adverse events (number of participants) was higher in the surgery group (14/60 (23.3%)) than in the radiofrequency ablation group (1/60 (1.7%)) (odds ratio 17.96, 95% CI 2.28 to 141.60; 120 participants; 1 trial). The number of serious adverse events was higher in the surgery group (adjusted rate 11.3 events per 100 participants) than in the radiofrequency ablation group (3/186 (1.6 events per 100 participants)) (rate ratio 7.02, 95% CI 2.29 to 21.46; 391 participants; 2 trials; I² = 0%). None of the trials reported health-related quality of life. One trial was funded by a party with vested interests; three trials were funded by parties without any vested. Non-surgical interventionsThe majority of participants had cirrhotic livers, and the hepatocellular carcinoma was of viral aetiology. Most trials did not report the portal hypertension status of the participants, and none of the trials reported whether the participants received adjuvant antiviral treatment or adjuvant immunotherapy. The average follow-up ranged from 6 months to 37 months (11 trials). Trial participants, who were not eligible for surgery, were treated with radiofrequency ablation, laser ablation, microwave ablation, percutaneous acetic acid injection, percutaneous alcohol injection, a combination of radiofrequency ablation with systemic chemotherapy, a combination of radiofrequency ablation with percutaneous alcohol injection, a combination of transarterial chemoembolisation with percutaneous alcohol injection, or a combination of transarterial chemoembolisation with radiofrequency ablation.The mortality at maximal follow-up was higher in the percutaneous acetic acid injection (hazard ratio 1.77, 95% CI 1.12 to 2.79; 125 participants; 1 trial) and percutaneous alcohol injection (hazard ratio 1.49, 95% CI 1.18 to 1.88; 882 participants; 5 trials; I² = 57%) groups compared with the radiofrequency ablation group. There was no evidence of a difference in all-cause mortality at maximal follow-up for any of the other comparisons. The proportion of people with cancer-related mortality at maximal follow-up was higher in the percutaneous alcohol injection group (adjusted proportion 16.8%) compared with the radiofrequency ablation group (20/232 (8.6%)) (odds ratio 2.18, 95% CI 1.22 to 3.89; 458 participants; 3 trials; I² = 0%). There was no evidence of a difference in any of the comparisons that reported serious adverse events (number of participants or number of events). None of the trials reported health-related quality of life. Five trials were funded by parties without any vested interest; the source of funding was not available in the remaining trials.

AUTHORS' CONCLUSIONS

The evidence was of low or very low quality. There was no evidence of a difference in all-cause mortality at maximal follow-up between surgery and radiofrequency ablation in people eligible for surgery. All-cause mortality at maximal follow-up was higher with percutaneous acetic acid injection and percutaneous alcohol injection than with radiofrequency ablation in people not eligible for surgery. There was no evidence of a difference in all-cause mortality at maximal follow-up for the other comparisons. High-quality RCTs designed to assess clinically important differences in all-cause mortality and health-related quality of life, and having an adequate follow-up period (approximately five years) are needed.

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach

BACKGROUND

The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM).

METHODS

A consecutive series of patients (n = 153) undergoing primary TLM for oropharyngeal SCC from 2006 to 2013 was studied. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry and high-risk HPV DNA in situ hybridization. Survival analyses were evaluated using Kaplan-Meier statistics.

RESULTS

Tumor subsites included tonsil (n = 94; 61.5%), tongue base (n = 38; 24.8%), and soft palate (n = 21; 13.7%), with the majority being American Joint Committee on Cancer (AJCC) stage III/IVa (n = 124; 81.0%) and HPV-positive (n = 101; 66.0%). Three-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 84.5%, 91.7%, and 78.2%, respectively. HPV-positivity portended favorable oncologic outcomes. One-year gastrostomy tube (G-tube) dependency was 1.3%.

CONCLUSION

To the best of our knowledge, this is the largest single-center TLM oropharyngeal SCC series to date. Our data suggest that TLM +/- postoperative radiotherapy (PORT) results in at least as good oncologic outcomes as chemoradiotherapy (CRT), while conferring swallowing function advantages. © 2016 Wiley Periodicals, Inc. Head Neck , 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38:1263-1270, 2016.

Abnormal umbilical artery Doppler findings in the recipient twin before laser surgery for twin-twin transfusion syndrome

OBJECTIVES

In twin-twin transfusion syndrome (TTTS), persistent absent or reversed end-diastolic flow in the umbilical artery is a rare finding in the recipient twin, and the clinical implications of this finding are not well characterized. We sought to study the clinical importance of abnormal umbilical artery Doppler waveforms in recipient twins and determine the perinatal survival of these twins after laser surgery.

METHODS

A retrospective study of patients with TTTS treated with laser surgery between 2006 and 2012 was conducted. Recipient twins with absent or reversed umbilical artery end-diastolic flow on preoperative sonography were identified, and clinical and perinatal outcomes were compared to the remaining cohort. Statistical analyses were performed with Fisher exact and χ(2) tests.

RESULTS

Of 369 consecutive TTTS cases, 14 (3.8%) had absent or reversed umbilical artery end-diastolic flow in the recipient twin. The rate of hydrops was higher in this group compared to those without absent or reversed flow (35.7% [5 of 14] versus 10.1% [36 of 355]; P = .0125). The rate of recipient twin growth restriction was also higher in the absent or reversed flow group (28.6% [4 of 14] versus 3.9% [14 of 355]; P = .0029). There was an increased rate of recipient fetal demise within 24 hours after surgery in those with absent or reversed flow (21.4% [3 of 14] versus 2.5% [9 of 355]; P = .0078), although there was no statistical difference in 30-day survival between the groups (78.6% [11 of 14] versus 89.9% [319 of 355]; P = .1751).

CONCLUSIONS

Doppler findings of absent or reversed umbilical artery end-diastolic flow are rare in recipient twins. Although immediate post-laser surgery survival is relatively decreased in this group, overall perinatal survival rates appear to be favorable.

Transmyocardial laser revascularization versus medical therapy for refractory angina

BACKGROUND

This is an update of a review previously published in 2009. Chronic angina and advanced forms of coronary disease are increasingly more frequent. In spite of the improvement in the efficacy of available revascularization treatments, a subgroup of patients continue suffering from refractory angina. Transmyocardial laser revascularization (TMLR) has been proposed to improve the clinical situation of these patients.

OBJECTIVES

To assess the effects (both benefits and harms) of TMLR versus optimal medical treatment in people with refractory angina who are not candidates for percutaneous coronary angioplasty or coronary artery bypass graft, in alleviating angina severity, reducing mortality and improving ejection fraction.

SEARCH METHODS

We searched the following resources up to June 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the metaRegister of Controlled Trials database, ClinicalTrials.gov, and the WHO International Clinical Trials Registry. We applied no languages restrictions. We also checked reference lists of relevant papers.

SELECTION CRITERIA

We selected studies if they fulfilled the following criteria: randomized controlled trials (RCTs) of TMLR, by thoracotomy, in patients with Canadian Cardiovascular Society or New York Heart Association angina grade III-IV who were excluded from other revascularization procedures.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data for each trial about the population and interventions compared and assessed the risk of bias of the studies, evaluating randomisation sequence generation, allocation concealment, blinding (of participants, personnel and outcome assessors), incomplete outcome data, selective outcome reporting, and other potential sources of bias.

MAIN RESULTS

From a total of 502 references, we retrieved 47 papers for more detailed evaluation. We selected 20 papers, reporting data from seven studies, which included 1137 participants, of which 559 were randomized to TMLR. Participants and professionals were not blinded, which suggests high risk of performance bias. Overall, 43.8% of participants in the treatment group decreased two angina classes, as compared with 14.8% in the control group: odds ratio (OR) 4.63, 95% confidence interval (CI) 3.43 to 6.25), and heterogeneity was present. Mortality by intention-to-treat analysis was similar in both groups at 30 days (4.0% in the TMLR group and 3.5% in the control group), and one year (12.2% in the TMLR group and 11.9% in the control group). However, the 30-day mortality as-treated was 6.8% in the TMLR group and 0.8% in the control group (pooled OR was 3.76, 95% CI 1.63 to 8.66), mainly due to a higher mortality in participants crossing from standard treatment to TMLR. The assessment of subjective outcomes, such as improvement in angina, was affected by a high risk of bias and this may explain the differences found. Other adverse events such as myocardial infarction, arrhythmias or heart failure, were not considered in this review, as they were not predefined outcomes in trials design and they show a high inconsistency across studies. No new trials on transmyocardial laser revascularization have been published in the last ten years and it is very unlikely that new research will be undertaken in this field.

AUTHORS' CONCLUSIONS

This review shows that risks associated with TMLR outweigh the potential clinical benefits. Subjective outcomes are subject to high risk of bias and no differences were found in survival, but a significant increase in postoperative mortality and other safety outcomes suggests that the procedure may pose unacceptable risks.

Intrafetal laser treatment for twin reversed arterial perfusion sequence: cohort study and meta-analysis

OBJECTIVES

To ascertain the outcome of twin reversed arterial perfusion (TRAP) sequence cases managed in our unit and to review systematically cases reported in the literature treated with intrafetal laser therapy.

METHODS

This was a retrospective cohort study of all TRAP sequence cases identified from 2000 to 2012 at our center. Pregnancy management and outcomes were ascertained from maternal and neonatal records. We also performed a meta-analysis of the literature on the use of intrafetal laser therapy for the treatment of TRAP. Adverse pregnancy outcome was defined as a composite of intrauterine death (IUD) and preterm birth before 37 weeks' gestation.

RESULTS

Twenty-three cases of TRAP were identified during the study period. Six were managed conservatively and 17 were treated with laser therapy. All cases managed conservatively were complicated by IUD at a median gestational age of 14 + 4 (interquartile range (IQR), 12 + 4 to 16 + 5) weeks. Among the treated cases, 14 (82%) delivered a healthy twin at a median gestational age of 37 + 1 (IQR, 34 + 0 to 38 + 3) weeks. Ten studies were reviewed in detail and the data were combined with those from the current study. The overall neonatal survival was 80%. Adverse pregnancy outcome was significantly lower when the treatment was performed before 16 weeks' gestation (19 vs 66%, P = 0.0025).

CONCLUSION

The study data demonstrate a high risk of spontaneous fetal demise in early pregnancy, lack of accurate prognostic markers and improved pregnancy outcome after laser therapy in cases of TRAP. In these cases we recommend elective treatment with intrafetal laser therapy at between 13 and 16 weeks' gestation.

Fetal cardiac function in recipient twins undergoing fetoscopic laser ablation of placental anastomoses for Stage IV twin-twin transfusion syndrome

OBJECTIVE

Cardiac dysfunction is common in the recipient fetus of twin-twin transfusion syndrome (TTTS). In this study, we aimed to document the severity of fetal cardiac dysfunction in Stage IV TTTS (fetal hydrops) and assess evolution of cardiac function longitudinally after fetoscopic laser surgery.

METHODS

We reviewed obstetric ultrasound examination data, pre- and postoperative echocardiograms and neonatal outcomes for 22 cases of Stage IV TTTS undergoing fetoscopic laser ablation of placental anastomoses between 1998 and 2011. Myocardial performance index, atrioventricular valve flow patterns, ventricular shortening fraction, ventricular hypertrophy, outflow tract obstruction and venous Doppler waveforms were assessed.

RESULTS

Nineteen fetuses (86.4%) had ascites, eight (36.4%) had pleural effusions, nine (40.9%) had a pericardial effusion and 12 (54.5%) had subcutaneous edema at presentation. Preoperatively, cardiac function was grossly abnormal in all. Eight fetuses (36.4%) had functional pulmonary atresia and one (4.5%) had functional aortic atresia. Seventy-seven percent of recipient fetuses survived until birth. Postoperative echocardiographic follow-up (mean, 26 days) showed that indices of fetal cardiac function improved considerably, but never completely normalized. Six of the eight fetuses with functional pulmonary atresia (75.0%), as well as the fetus with functional aortic atresia, survived to birth. In all cases, the functional atresia resolved within 48 h of laser ablation therapy and none had structural valve anomalies at birth. All fetal effusions resolved after the laser.

CONCLUSIONS

Fetoscopic laser ablation of placental anastomoses reverses cardiac dysfunction and valvulopathy, even in the most severe cases of TTTS. However, recovery takes longer than in early stage disease.

Myocardial Laser Revascularization in the Year 2000 as seen by a Norwegian Specialist Panel. The Process of Evaluating and Implementing New Methods in Clinical Practice

OBJECTIVE

In Norway "Transmyocardial laser revascularization" as a routine method was prohibited by the Ministry of Health in 1995 due to lacking evidence of treatment effect and concerns about procedural morbidity and mortality. In 1999 Norwegian health authorities asked for a re-evaluation of the method based on a systematic review of literature.

METHODS

Medline and Embase were searched and a total of 267 articles were identified. Publications were classified by an expert panel according to type of study and importance for the project.

RESULTS

Based on the literature review the panel concluded that heart laser treatment does not have a life-saving effect, nor does it improve myocardial function. However, the method has a considerable short-term symptomatic effect, the mechanism of which is not understood. Neoangiogenesis, denervation and placebo may play a role. Based on the report the Norwegian health authorities recommended use of this method be restricted to scientific trials only.

CONCLUSIONS

Based on a systematic literature review it was concluded that the only documented effect of heart laser treatment is symptom relief, the mechanism for which is unclear. It could partly or totally be a placebo effect. A conflict of interest may arise when new technologies are to be implemented in health care. The communication between professionals evaluating scientific results and decision makers is challenging. Quality assurance of this process may be obtained by use of expert panels working under the auspices of an official institution.

Transmyocardial laser revascularization: from randomized trials to clinical practice. A review of techniques, evidence-based outcomes, and future directions

Cardiac surgeons are increasingly faced with a more complex patient who has developed a pattern of diffuse coronary artery disease that cannot be completely revascularized by CAGB alone. Considering the increased operative and long-term cardiac risks predicted by incomplete revascularization, and the documented operative and long-term benefits associated with sole therapy and adjunctive TMR in randomized patients with diffuse coronary artery disease, increased use of sole therapy and adjunctive TMR therapy is warranted.

Laser Lead Extraction: Predictors of Success and Complications

BACKGROUND

Paralleling the rise in pacemaker and defibrillator implantations, lead extraction procedures are increasingly required. Concerns regarding failure and complications remain.

METHODS AND RESULTS

A total of 200 lead extraction procedures were performed at the Montreal Heart Institute between September 2000 and August 2005. In 23 patients, all leads were removed by traction with a locking stylet. A total of 270 leads were extracted using a laser sheath system (Spectranectics, Colorado Springs, CO, USA) in 177 procedures involving 175 patients (74% male), age 62+/-16 years. Procedural indications were: infection 88 (50%), dysfunction 54 (30%), upgrade 21 (12%), and other 14 (8%). Overall, 241 leads (89%) were successfully extracted, 7 (3%) were partially extracted (< or = 4 cm retained), and 22 (8%) were non-extractable. In multivariate analyses, predictors of failed extraction were longer time from implant (OR 1.16 per year, P=0.0001) and history of hypertension (OR 5.2, P=0.0023). Acute complications occurred in 14 of 177 procedures (7.9%): 8 (4.5%) minor and 6 (3.4%) major, with one death. In multivariate analyses, the only predictor of acute complications was laser lead extraction from both right and left sides during the same procedure (OR 9.4, P = 0.0119). In addition, 3 of 10 patients with failed or partially extracted infected systems eventually required open chest explantation because of endocarditis.

CONCLUSION

Most leads not amenable to manual traction may be successfully extracted by a percutaneous laser sheath system. While most complications are minor, major complications including death may occur. Older leads are at higher risk for failed extraction. Endocarditis may ensue if infected leads are incompletely removed.

Evolution of the management approach for pulmonary atresia with intact ventricular septum

OBJECTIVE

To review the evolution of the management approach for pulmonary atresia with intact ventricular septum (PAIVS) in the past two decades and to assess its impact on patient outcomes.

DESIGN AND PATIENTS

Retrospective review of the management and outcomes of 94 patients (55 male patients) with PAIVS diagnosed between July 1980 and August 2003.

SETTINGS

Tertiary paediatric cardiac centre.

RESULTS

Seven patients died before interventions. Of the remaining 87 patients who underwent intervention at a median age of 9 days (from 1 day to 2 years), 12 had right ventricular outflow tract reconstruction (RVOTR), 42 had closed pulmonary valvotomy (CPV), and 15 had laser assisted valvotomy with balloon valvoplasty. A systemic-pulmonary shunt was inserted in 18 patients, six of whom had subsequent RVOTR (n = 4) or laser assisted valvotomy (n = 2). Since 1990, catheter intervention accounted for 38% (17 of 45) of the right ventricular outflow procedures. The mean (SEM) freedom from reintervention was 93 (7)%, 71 (12)%, and 57 (13)% after RVOTR, 75 (7)%, 40 (8)%, and 14 (6)% after CPV, and 54 (13)%, 24 (12)%, and 16 (10)% after laser assisted valvotomy at one month, six months, and one year, respectively (RVOTR versus CPV, p < 0.001; RVOTR versus laser assisted valvotomy, p = 0.001). Low cardiac output syndrome was significantly less common after catheter intervention than after RVOTR (0% v 44%, p = 0.003) or CPV (0% v 29%, p = 0.01). The overall mean (SEM) survival was 77 (5)% and 70 (5)% at one and five years, respectively, and the overall mortality was 33% (29 of 87). There were no significant differences in survival between the three groups.

CONCLUSIONS

Multiple interventions are often required in the treatment algorithm of PAIVS. The shift towards increased use of the transcatheter approach has reduced the occurrence of postprocedural low cardiac output syndrome.

Eight years experience of high-powered endoscopic diode laser therapy for palliation of colorectal carcinoma

PURPOSE

Endoscopic laser therapy using neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has been shown to be effective in palliating symptoms of obstruction, bleeding, and discharge in patients with colorectal cancer. These patients usually have advanced inoperable disease at presentation or are unfit for surgery. We have used high-powered diode laser to palliate patients with inoperable colorectal cancer since 1994. This study was designed to determine the success rate of high-powered diode laser in palliating inoperable colorectal carcinoma and compare these figures with those published for Nd:YAG laser.

METHODS

A retrospective analysis was performed of all patients undergoing high-powered diode laser therapy for colorectal carcinoma between June 1994 and October 2002 (inclusive) at St. George's Hospital, London, United Kingdom. Patient's notes and endoscopy records were reviewed to determine the indications for treatment, success of symptom palliation, complications, and survival for each patient.

RESULTS

Fifty-seven patients (28 males), with a median age at first treatment of 82 (range, 51-93) years, were identified who had been palliated with high-powered diode laser therapy for colorectal carcinoma. The median number of treatments received by each patient was three (range, 1-16 treatments), with a median interval between treatments of 9.5 (range, 1-25) weeks. Lifelong palliation of symptoms occurred in 51 patients (89 percent). Major complications were two perforations and one hemorrhage, giving an overall complication rate of 5.3 percent. One of the patients who experienced perforation died, giving an overall mortality rate of 1.8 percent for the procedure. The median survival of the 51 patients palliated completely by laser therapy was 8.5 (range, 0.6-52) months, with a probability of survival at 24 months of 15 percent.

CONCLUSIONS

High-powered diode laser therapy is an effective method of providing palliation for obstruction, bleeding, and discharge in those patients with inoperable colorectal carcinoma. It produces results comparable to therapy with Nd:YAG laser and the equipment is cheaper, more compact, and portable.

Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting: a randomized, multicenter study with 4-year follow-up

We evaluated transmyocardial laser revascularization (TMLR) with coronary artery bypass grafting (CABG) versus CABG alone for severe coronary artery disease involving 21 myocardial region unsuited for CABG. At 4 centers, 44 consecutive patients were randomized for CABG+TMLR (n = 23) or CABG alone (n = 21). Operative and in-hospital mortality and morbidity rates were monitored. Clinical status was evaluated at hospital discharge, 1 year, and 4 years. Success was characterized by relief of angina and freedom from repeat revascularization and death. Preoperatively, 20 patients (47%) were at high risk. The CABG technique, number of grafts, and target vessels were similar in both groups. Patients undergoing CABG+TMLR received 25 +/- 11 laser channels. Their < or = 30-day mortality was 13% (3/23) compared with 28% (6/21) after CABG alone (P = 0.21). There were no significant intergroup differences in the number of intraoperative or in-hospital adverse events. The follow-up period was 50.3 +/- 17.8 months for CABG alone and 48.1 +/- 16.8 months for CABG+TMLR. Both groups had substantially improved angina and functional status at 1 and 4 years, with no significant differences in cumulative 4-year mortality. The incidence of repeat revascularization was 24% after CABG alone versus none after CABG+TMLR (P < 0.05). The 4-year event-free survival rate was 14% versus 39%, respectively (P < 0.064). In conclusion, CABG+TMLR appears safe and poses no additional threat for high-risk patients. Improved overall success and repeat revascularization rates may be due to better perfusion of ischemic areas not amenable to bypass. Further studies are warranted to determine whether these trends are indeed significant.

[Coronary artery bypass graft combined with transmyocardial laser revascularization. Survival and functional class at one-year follow-up]

INTRODUCTION AND OBJECTIVES

The use of Transmyocardial Laser Revascularization (TMLR) as a strategy to treat unstable angina has been reported in many studies. We analyze its safety and effectiveness in combined procedures (CABG + TMLR).

METHODS

A non-randomized, retrospective cohort study was performed from May 4, 1999 to May 25, 2000 in 21 TMLR patients (18 combined CABG + TMLR) and 118 CABG only procedures. Mortality and NYHA analyses were determined by telephone at follow-up.

RESULTS

Three hospital deaths were observed: one isolated TMLR patient, one valvular + CABG + TMLR patient, and one CABG + TMLR patient. A significantly higher incidence of preoperative angina was found in the group of patients with TMLR + CABG, than in the group with only CABG (83 vs 25%; p < 0.001). There were no differences in age, gender, ejection fraction, Parsonnet and EuroSCORE risk estimation, or mortality (5.1% isolated CABG, 5.6% combined). No episode of angina was detected during follow-up in the CABG + TMLR group: 88% patients were NYHA I, and 21% NYHA II.

CONCLUSION

Incomplete coronary revascularization may be complemented with TMLR in the areas in which CABG is not possible without increased mortality. This technique may avoid postoperative unstable angina due to residual ischemic areas.

Transmyocardial laser revascularization

Low-powered lasers were first used in the early 1980s to produce transventricular channels as an adjunct to coronary artery bypass graft surgery (CABG). Early results were encouraging, but because of the combined procedure, could not be attributed directly to use of the laser [1]. High-powered lasers were introduced into clinical practice in 1990 [2]. These lasers are powerful enough to create a transmyocardial channel with minimal thermal damage to surrounding tissues [3]. Clinical studies, using transmyocardial laser revascularization (TMR) as the sole operative therapy for patients with severe and diffuse coronary artery disease (CAD) who have Class III or IV angina, and are on medical therapy, have been conducted since 1993. Based on the results of these studies, the FDA granted approval for the use of TMR as a sole therapy. Clinical studies are currently underway to assess the results of combined TMR and CABG [4]. Results of four controlled randomized studies have been published [5-8]. The data from two of these studies formed the basis for FDA approval of two different types of laser systems. The results of these studies have not provided any additional insights into the mechanism of action of TMR, which remains the Achilles' heel of this procedure. In this review, background information about the TMR procedure will be discussed along with an analysis of the recently published randomized studies.

Transmyocardial laser revascularization in ischemic cardiomyopathy

BACKGROUND

In ischemic cardiomyopathy (left ventricular ejection fraction [LVEF] < or = 30%), myocardial revascularization by coronary artery surgery has better results than heart transplantation, provided there is sufficient ischemic but viable myocardium. The mode of action of transmyocardial laser revascularization (TMR) is still being debated, but if the procedure induces improved myocardial perfusion it could be a "bridge," or alternative, to heart transplantation.

METHODS

We retrospectively analyzed 194 patients, who underwent TMR between July 1997 and October 1999. Patients with TMR as an adjunct to coronary artery surgery (n = 30) and those who did not provide written consent to the procedure (n = 8) were excluded; 126 patients had normal or moderately reduced left ventricular function, and 30 patients with ischemic cardiomyopathy (LVEF < or = 30%) were included.

RESULTS

After 12 months, the Canadian Cardiovascular Society (CCS) score dropped significantly from 3.6 (3 to 4) to 2.4 (1 to 4) and maximum work load increased significantly from 58 W (25 to 100 W) to 73 W (25 to 120 W). However, thallium score and LVEF did not improve significantly (27% [15% to 30%] to 32% [15% to 45%]). Prior to the TMR procedure, all 30 patients had a "low risk" or "medium risk" of death according to the Aaronson classification. The 30-day, 1-year, and 2-year survival rates were 83%, 50%, and 47%, respectively.

CONCLUSIONS

We conclude that TMR in ischemic cardiomyopathy (LVEF < or = 30%) has a perioperative risk comparable to that for heart transplantation, but there is no improvement of myocardial performance or life expectancy. Therefore, TMR cannot be regarded as a "bridge," or alternative, to transplantation. However, in individual cases with contraindications for transplantation the anti-anginal effect may justify use of the procedure.

Transmyocardial laser revascularization: is the enthusiasm justified?

BACKGROUND

Transmyocardial laser revascularization (TMLR) is advocated to offer relief of incapacitating angina for patients whose coronary vessels are poor targets for coronary artery bypass graft surgery (CABG) or balloon angioplasty and stenting. In spite of significant mortality and morbidity, the preliminary reports from centers performing the procedure were quite enthusiastic for a period of about 1 year following the procedure.

HYPOTHESIS

The study aimed to determine mortality, morbidity, and long-term results of TMLR.

METHODS

The study included 19 individuals with incapacitating angina not suitable for CABG or percutaneous balloon angioplasty. Patients were followed up clinically for death, myocardial infarction, heart failure, arrhythmia, and repeated hospital admissions for unstable angina or other conditions. Stress testing with radionuclide tracers was done following surgery in patients who were not unstable.

RESULTS

Of 19 patients, 8 experienced significant morbidity. There was one hospital death. Four died within 17 months. Relief from angina of two classes or more was present in 15 of 18 patients (83.3%) for a variable time period. Mean time for anginal relief was 8.0 months (range 1-30 months). At last follow-up, only two patients with a hybrid procedure (both CABG and TMLR in the same sitting) had mild angina for 17 and 29 months, respectively. All others with a mean follow-up period of 21.2 months (range 6-53 months) developed unstable angina or had a large area of ischemia on stress radionuclide studies. Despite a high incidence of significant angina in patients after TMLR, hospitalization was reduced from an average of 42.6 days pre procedure in the year before to 21 days during the follow-up period post procedure.

CONCLUSION

Transmyocardial laser revascularization is associated with significant relief of angina pectoris in the majority of patients with severe diffuse coronary artery disease; however, this relief is short-lived in most. When mortality and morbidity are factored in, TMLR cannot be enthusiastically recommended.

Transmyocardial revascularization--late results and mechanisms of action

Transmyocardial revascularization (TMR) has been used in over 500 patients to relieve severe angina when all other measures failed: two different lasers were used in the study. Each has been successful, but, in the author's experience, the Carbon Dioxide laser has given better relief of angina and increase in perfusion than the Holmium-YAG laser. Based on these clinical observations, the probable mechanism of action is stimulation of vascular neogenesis plus improved distribution of the available blood supply.

Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris. Clinical results from the Norwegian randomized trial

OBJECTIVES

The purpose of the study was to evaluate clinical effects, exercise performance and effect on maximal oxygen consumption (MVO2) of transmyocardial revascularization with CO2-laser (TMR) in patients with refractory angina pectoris.

BACKGROUND

Transmyocardial laser revascularization is a new method to treat patients with refractory angina pectoris not eligible for conventional revascularization. Few randomized studies comparing TMR with conventional treatment have been published.

METHODS

One hundred patients with refractory angina not eligible for conventional revascularization were block-randomized in a 1:1 ratio to receive continued optimal medical treatment (MT) or TMR in addition to MT. The patients were evaluated at baseline and at three and 12 months with end points to symptoms, exercise capacity and MVO2.

RESULTS

Transmyocardial laser revascularization resulted in significant relief in angina symptoms after three and 12 months compared to baseline. Time to chest pain during exercise increased from baseline by 78 s after three months (p = NS) and 66 s (p < 0.01) after 12 months in the TMR group, whereas total exercise time and MVO2 were unchanged. No significant changes were observed in the MT group. Perioperative mortality was 4%. One year mortality was 12% in the TMR group and 8% in the MT group (p = NS.)

CONCLUSIONS

Transmyocardial laser revascularization was performed with low perioperative mortality and caused significant symptomatic improvement, but no improvement in exercise capacity.

Current status of transmyocardial laser revascularization: review of the literature

BACKGROUND

Transmyocardial laser revascularization (TMLR) is a new procedure for the treatment of angina pectoris in which high power laser energy is used to create channels in ischemic myocardium.

OBJECTIVE

To describe in detail the historical, experimental and state-of-the-art studies regarding TMLR.

DATA SOURCES

The English-language literature published from 1966 to 1998 was thorougly searched in MEDLINE. Further information regarding unpublished data was obtained on request.

STUDY SELECTION

The most important experimental studies and randomized prospective clinical trials were examined. Additional papers were selected to provide a historical perspective and future prospects of TMLR.

DATA SYNTHESIS

Although the results of TMLR in terms of angina relief are impressive, the procedure is associated with significant mortality and morbidity, and the results of objective cardiac perfusion measurements such as radionucleic perfusion scans and positron emission tomography are not conclusive. Furthermore, little information is available concerning the effect of this procedure on life expectancy. This article reviews the historical background of TMLR and possible mechanisms by which it may work, and discusses existing evidence for and against the procedure and how it may be applied in the future.

CONCLUSIONS

At present, TMLR is potentially indicated for patients with severe angina that is refractory to medical therapy and who have contraindications for the more traditional therapies (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty and transplantation). More data are needed to evaluate fully the indications for this procedure.

The transmyocardial laser revascularization international registry report

AIMS

This report aimed to provide an analysis of the data submitted from Europe and Asia on transmyocardial laser revascularization.

METHODS AND RESULTS

Prospective data was recorded on 967 patients with intractable angina not amenable to conventional revascularization in 21 European and Asian centres performing transmyocardial laser revascularization using the PLC Medical Systems CO2 laser. Patient characteristics, operative details and early complications following transmyocardial laser revascularization were recorded. The in-hospital death rate was 9.7% (95% confidence interval 7.8% to 11.6%). Other early complications were consistent with similar cardiothoracic surgical procedures. There was a decrease of two or more Canadian Cardiovascular Score angina classes in 47.3%, 45.4% and 34.0% of survivors at 3, 6 and 12 months follow-up, respectively (P=0.001 for each). Treadmill exercise time increased by 42 s at 3 months (P=0.008), 1 min 43 s at 6 months (P<0.001) and 1 min 50 s at 12 months (P<0.001) against pre-operative times of 6 min.

CONCLUSION

Uncontrolled registry data suggest that transmyocardial laser revascularization may lead to a decrease in angina and improved exercise tolerance. It does, however, have a risk of peri-operative morbidity and mortality. Definitive results from randomized controlled trials are awaited.

Early results of transmyocardial revascularization with a holmium laser

BACKGROUND

Transmyocardial laser revascularization (TMLR), a surgical technique designed to improve perfusion in the ischemic myocardium by creating transmural channels, has been performed thus far using a carbon dioxide laser, with apparently gratifying early results. We have investigated clinically TMLR using a holmium laser as sole therapy for patients with coronary artery disease that is not amenable to traditional treatment such as coronary artery bypass grafting or percutaneous transluminal coronary angioplasty.

METHODS

From November 1995 to December 1996, 16 patients underwent TMLR using a holmium laser. Their mean age was 68 +/- 6 years and 75% were men. Previous coronary artery bypass grafting or percutaneous transluminal coronary angioplasty had been performed in 81% and 31% of the patients, respectively. Before operation, their mean anginal class was 3.4 +/- 0.5 and their mean left ventricular ejection fraction was 0.49 +/- 0.06. Six patients had unstable angina.

RESULTS

There were no operative deaths. The mean duration of TMLR was 27 +/- 13 minutes and the mean duration of the entire operation was 120 +/- 40 minutes. There were no major postoperative complications and the mean hospital stay was 8 +/- 4 days. There were 2 late deaths, 1 that occurred 40 days after TMLR as a result of stroke and 1 that occurred 4 months after TMLR as a result of myocardial infarction. Current survivors have been followed up for a mean of 10 +/- 4 months (range, 3 to 15 months), with 7 patients followed up for 1 year. At last follow-up, the mean anginal class had decreased to 1.8 +/- 0.7 (p = 0.001) and the patients had increased exercise tolerance and a reduced number of hospitalizations. However, no statistically significant changes in the percentage of segments with fixed or reversible ischemia and no statistically significant differences in the viability scores of lased and nonlased segments were observed.

CONCLUSIONS

Transmyocardial laser revascularization using a holmium laser is a simple technique with low operative risk and low morbidity. Early results confirm that clinical improvement is obtained in most patients, although significant changes in myocardial perfusion are not evident in the short term.

[The VLAP system (Visual Laser Ablation of the Prostate): comparative study of the contact versus non-contact techniques in a series of 100 cases]

OBJECTIVE

To compare two contact and non-contact techniques using the VLAP system (visual laser ablation of the prostate).

PATIENTS AND METHOD

From January 1994 to April 1995, two groups of 50 patients were included in a randomized prospective study and were treated by the contact and non-contact laser technique, respectively. These patients presented with symptomatic BPH requiring transurethral electroresection. These patients were evaluated according to subjective (AUA score) and objective criteria (maximum flow rate, transrectal and suprapubic ultrasonography). ND:YAG laser energy was delivered by a Medilas 4100 source via a lateral beam fibre. Objective success criteria were an improvement of the AUA score by at least 50% and of the maximum flow rate by at least 50% with a difference of 4 mL/s. The failure criterion was the need to perform complementary electroresection during the first 6 postoperative months.

RESULTS

The mortality was 2% (cardiovascular causes), and the overall morbidity (first postoperative month) was 29%, with 21% of a vesical irritation syndrome, 6% of urinary tract infection and 2% of bladder clots. The global result at 12 months showed a statistically significant postoperative improvement of the subjective and objective parameters studied preoperatively (p = 0.0001). In the contact group, the AUA score, mean maximum flow rate and residual urine, which had preoperative values of 19.1, 9.1 mL/s and 141 mL, respectively, were equal to 2.3, 15.6 mL/s and 45 mL at 12 months. In the non-contact group, the same parameters, which had preoperative values of 17.8, 9.2 mL/s and 87 mL, respectively, were equal to 3.8, 13.3 mL/s and 47 mL at 12 months. The results, evaluated as a function of objective success criteria, showed a 12-month success rate of 68% for the contact method and 61% for the non-contact method. The mean hospital stay was 6 days and the mean duration of bladder catheterization was 5 days with the two techniques. During follow-up, 7% of patients required revision by electroresection, regardless of the technique used.

CONCLUSION

this study demonstrated identical results for the contact and non-contact techniques using the VLAP system.

Transmyocardial laser revascularization: results of a multicenter trial with transmyocardial laser revascularization used as sole therapy for end-stage coronary artery disease

BACKGROUND

Transmyocardial laser revascularization was used as the sole therapy for patients with ischemic heart disease not amenable to percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. This technique uses a carbon dioxide laser to create transmyocardial channels for direct perfusion of the ischemic heart.

METHODS

Since 1992, 200 patients, at eight hospitals in the United States, have undergone transmyocardial laser revascularization. The patients have a combined 1560 months of follow-up for an average of 10 +/- 3 months per patient. Their age was 63 +/- 10 years and their ejection fraction was 47% +/- 12%. Eighty-two percent had at least one previous bypass graft operation and 38% had a prior angioplasty. Preoperatively, the patients underwent nuclear single photon emission computed tomography perfusion scans to identify the extent and severity of their ischemia. These scans were repeated at 3, 6, and 12 months. Angina class, admissions for angina, and medications were recorded.

RESULTS

The perioperative mortality was 9%. Angina class decreased significantly from before treatment to 3, 6, and 12 months (p < 0.001). Likewise, there was a significant decrease in the number of perfusion defects in the treated left ventricular free wall. Concomitantly, there was a significant decrease in the number of admissions for angina in the year after the procedure when compared with the year before treatment (2.5 vs 0.5 admissions per patient-year).

CONCLUSION

These combined results indicate that transmyocardial laser revascularization provides angina relief, decreases hospital admissions, and improves perfusion in patients with severe coronary artery disease.

Histological findings after transmyocardial laser revascularization

In recent time, it has become more and more probable that patients with severe diffuse coronary artery disease, who are not candidates for aortocoronary bypass surgery or percutaneous transluminal coronary angioplasty procedures, can benefit from transmyocardial laser revascularization (TMR). But the underlying principle of TMR still remains unclear. This study reports on a histological analysis of eight patients, in whom a total of 250 channels had been created, who died after TMR. The TMR channels were created by a CO2 laser surrounded by a zone of necrosis with an extent of about 500 microns. In the hearts of patients who died in the early postoperative period (1 to 7 days postoperative), almost all channels were closed by fibrin clots, erythrocytes, and macrophages. There were no obvious connections between the channels and the ventricular cavity. In specimens from patients, who died 2 or more weeks after the procedure, a granular tissue with high macrophage and monocyte activity was observable. Within this tissue, we observed a developing network of capillaries. Otherwise, the tissue filling the channels did not substantially differ from scar tissue. We failed to observe connections between the ventricular cavity and the new capillaries. Whether these vessels within the closed channels have any impact on myocardial perfusion remains unclear, but it seems unlikely that the clinical effects of TMR are based on the principle of the amphibian heart.

Morbidity and mortality after thoracoscopic pneumonoplasty

BACKGROUND

Both video-assisted thoracic surgery and open pneumonoplasty procedures have been used to achieve lung reduction in emphysema patients.

METHODS

The surgical and hospital course of 339 patients with a mean forced expiratory volume in 1 second of 750 mL and a mean ratio of forced expiratory volume in 1 second to forced vital capacity of 35% undergoing video-assisted thoracic surgical laser pneumonoplasty was analyzed.

RESULTS

The incidence of myocardial infarctions was 0.9% and the hospital mortality rate was 4.1%.

CONCLUSIONS

Factors leading to increased morbidity and mortality were advanced age (65 years and greater, especially greater than 75 years), sex (men greater than women), carbon dioxide retention in the resting state (especially an arterial carbon dioxide tension greater than 55 mm Hg), forced expiratory volume in 1 second less than 700 mL for men and 500 mL for women, maximum voluntary ventilation less than 25% predicted, and a ratio of residual volume/total lung capacity greater than 60%.

Laser therapy for endobronchial tumours

Endobronchial laser therapy has been performed at Knightswood Hospital, Glasgow since 1983. During the period 1983 to 1990, 62 patients underwent a total of 149 laser treatments. The principal indications for therapy were tracheo-carinal stridor (24%), dyspnoea due to bronchial occlusion (60%) and haemoptysis (13%). Squamous carcinoma accounted for 80% of the lesions. Over 75% of patients had already received some form of prior therapy (radiotherapy 71%, chemotherapy 8%, surgical resection 11%). Laser therapy reduced stridor in 67% of patients with tracheal and carinal tumours and produced symptomatic improvement in 72% of patients with bronchial obstruction but without evidence of lobar collapse. Haemoptysis was controlled in all but one of patients treated. Two patients (3.2%) died during laser treatment following severe haemorrhage.

Resection of abdominal hollow organs by laser

During a ten-year period 642 abdominal hollow organ resections have been performed by means of a new, original technique--that is, CO2 laser irradiation combined with specially designed instrumentation. This resulted in a remarkable decrease in postoperative morbidity and mortality. The article describes the laser procedure.

[Efficacy of using the laser scalpel in operations on the stomach and intestines]

An analysis of the article "Clinico-morphological estimation of regenerative processes of the stomach wound made by laser scalpel" by prof. A. I. Nechaĭ et al. published in the Journal "Vestnik khirurgii" No. 1, 1985 has shown that the authors committed a number of fundamental technical errors when performing experimental studies and operations on gastrointestinal organs in the clinic which were followed by unsatisfactory results and conclusions on inexpediency of using lasers for such operations. The 10-year experience of the All-Union Research Center of Laser Surgery of the USSR Ministry of Health as well as that of most researchers dealing with this problem proves the opposite--the use of laser technique was found to improve processes of healing the gastric and intestinal wounds and to reduce the amount of postoperative complications and lethality.