Transmyocardial laser revascularization (TMR) has been increasingly used during the past years in patients suffering from severe diffuse coronary artery disease. The therapy is based upon the creation of transmyocardial channels in the free wall of the left ventricle by means of a laser. Several prospective, controlled, randomized studies were able to show that after TMR 70% of the patients operated on experienced a marked decline in angina symptoms and an increase in physical endurance and quality of life. These effects seem o last for years, and a TMR procedure can then be repeated. Whereas the regional and global myocardial function seems not to be influenced by transmyocardial laser revascularization, the question of an improvement in myocardial perfusion is still unanswered. Diabetic patients seem to be less likely to respond to the laser treatment and to carry a significant higher risk for death during the first postoperative year. Like several other study groups we found the TMR channels created by a CO2 laser closed by fibrin clots, erythrocytes and macrophages in the first postoperative days. There were no connections obvious between the channels and the ventricular cavity. Within the surrounding of the channels, however, we observed a marked neoangiogenesis. Induction of angioneogenesis seems to by the underlying principle of TMR. CO2 laser TMR does not result in significant injury to the myocardium.

Untersuchungen zu klinischem Stellenwert und zugrundeliegenden Mechanismen der transmyokardialen Laserrevaskularisation

Abciximab (c7e3; ReoProR ; Centocor, Inc., Pennsylvania, USA), a Fab fragment of the chimeric human-murine monoclonal antibody directed against platelet glycoprotein IIb/IIIa receptors, has been shown to reduce acute ischemic complications in patients undergoing percutaneous coronary interventions (PCI). However, its use has been associated with an increased incidence of bleeding events. The aim of this study is to examine the frequency of bleeding complications and to identify clinical variables associated with it in our patients. We prospectively recorded incidence of bleeding complications in 344 consecutive patients who underwent PCI with adjunctive use of abciximab (Ab). Clinical predictors for patients who developed bleeding complications with Ab were compared with the nonbleeders. Major bleeding occurred in six patients (1.7%) one of whom had pulmonary hemorrhage and one had intracranial hemorrhage. Minor bleeding occurred in 20 (5.8%) patients. Thrombocytopenia was seen in 13 (3.9%) patients of which four (1.2%) were mild, four (1.2%) were severe, and five (1.5%) were profound. Multivariate analyses showed that female gender and the "bail-out" use of Ab were risk factors for bleeding complications. The rate of major bleeding complications and thrombocytopenia were low and comparable with published trials. Female patients and those who received Ab as a "bail-out" were at higher risk of developing bleeding complications. (J Interven Cardiol 2005;18:33-37)

Predictors of bleeding complications and thrombocytopenia with the use of abciximab during percutaneous coronary intervention.

In the past decade, new developments in cardiology and cardiac surgery have begun to offer patients a variety of new, less invasive options for the treatment of coronary artery disease. One such option is the hybrid approach to coronary artery revascularization. This combines minimally invasive direct coronary artery bypass surgery (MIDCAB) of the left anterior descending artery (LAD) with percutaneous coronary intervention (PCI) of the remaining diseased coronary arteries. This approach, as an alternative to conventional coronary artery bypass surgery, retains the benefit of internal mammary artery bypass to the LAD, accomplished with a minimally invasive technique, substitutes PCI for saphenous vein grafts as treatment for low-grade lesions of other coronary arteries, and may provide a maximally beneficial outcome for many patients. Preliminary outcomes of patients receiving the hybrid approach have been strikingly positive. This report highlights the rationale for the development of this procedure, patient selection, results, and future applications of this emerging method of treating coronary artery disease.

The hybrid approach to coronary artery revascularization: minimally invasive direct coronary artery bypass with percutaneous coronary intervention.

Introduction: The pattern of use of abciximab in real-life clinical patients undergoing percutaneous coronary intervention (PCI) in 11 high-volume centres in Singapore, Malaysia, Thailand, Philippines, India, Pakistan and Korea was prospectively examined. Methods: These centres enrolled 224 consecutive patients over eight months to receive abciximab during PCI for the study. The cohort consisted of 82.1 percent males, with mean age of 55 (+11) years and mean weight of 67 (+17) kg. Results: The use of abciximab during PCI ranged between 6.2 percent and 21.6 percent. The indications for the use of abciximab were: acute coronary syndromes (34.3 percent), complex coronary lesions (17.9 percent) and multivessel PCI (17.7 percent). Based on a risk scoring system devised for this registry, majority (60.0 percent) of the patients was considered high risk when abciximab was used. Among the patients enrolled, 36.6 percent received abciximab as a “bail-out”. The overall in-hospital ischaemic event rates were low at 4.0 percent. The complication rates included major bleeding 0.7 percent, thrombocytopenia 2.7 percent and need for blood transfusion 2.8 percent. There was a trend towards a higher incidence of in-hospital non-Q myocardial infarction in the “bail-out” group (2.1 percent versus 7.3 percent, p-value equals 0.07). Conclusion: Abxicimab was uncommonly used among patients (9.4 percent) undergoing PCI in this Asian region, with the operators reserving it mainly for high-risk patients.

ReoPro Observational Registry (RAPOR): insights from the multicentre use of abciximab in Asia.

The increased bleeding risk associated with the use of abciximab has been well reported. The risk appears to be amplified when abciximab is administered concurrently with a fibrinolytic agent. We report and review the literature on the occurrence of a case of fatal pulmonary haemorrhage, a rare bleeding complication, in a patient who received both these drugs.

Fatal pulmonary haemorrhage with the combined use of abciximab and fibrinolytic agent.

BACKGROUND Abciximab, a monoclonal antibody to platelet glycoprotein IIb/IIIa receptor, has been shown to be effective in reducing ischemic complications after coronary angioplasty in recent trials. However, little is known about its efficacy and safety when used in Asian patients. METHODOLOGY Based on our abciximab registry, we performed a retrospective analysis of 115 Asian patients who received the antiplatelet agent while undergoing percutaneous coronary intervention in our centre. They constituted 18.4% of the total number of patients undergoing percutaneous revascularisation during the corresponding period. The majority of the patients were males (84%). The mean age of the cohort was 54 and the mean weight was 70 kg. The ethnic composition of the study population was: Chinese 54%, Indians 21%, Malays 19% and Others 6%. All patients received aspirin 100 mg and weight-adjusted heparin before the procedure. Abciximab may be administered on a preplanned basis prior to the procedure or be given as a 'bailout' strategy. RESULTS There was a high clinical success rate of 95.8% and low incidence of ischemic complications when abciximab was given during coronary angioplasty. There were 0% Q myocardial infarction, 3.3% non-Q myocardial infarction and 0.8% death in our series. Bleeding complications were uncommon at 7.6%, predominantly involving the groin and gingiva. Thrombocytopenia occurred in 5.8% of patients. Abciximab was noted to increase the procedural activated clotting time (ACT) by 38 seconds when given concomitantly with heparin. The mean maximal procedural ACT achieved was 323 +/- 51 seconds. CONCLUSIONS Abciximab may be used safely and efficaciously in Asian patients undergoing coronary angioplasty. The drug confers protection against ischemic complications during the procedure whether it is administered electively or as a 'bailout'. There is however, a need to redefine the heparin regime for our patients, given the high ACT obtained when abciximab is administered.

The use of abciximab in coronary angioplasty--an Asian centre's experience.

Currently, 3 methods of myocardial revascularisation are available for the treatment of coronary artery disease: i) coronary artery bypass grafting (CABG); ii) percutaneous transluminal coronary angiography (PTCA), and iii) transmyocardial laser revascularisation (TMR). Until recently, these procedures were performed exclusive to one another. We report 2 cases of minimally invasive direct coronary artery bypass grafting with subsequent PTCA, and 1 case of staged PTCA followed by TMR performed at our institution. We discuss the role of hybrid procedures in the current era of treatment of ischaemic heart disease.

Hybrid cardiac revascularisation surgery.

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The use of abciximab in coronary angioplasty--an Asian centre's experience.

Hybrid cardiac revascularisation surgery.