title: Excimer laser angioplasty in acute myocardial infarction (the CARMEL multicenter trial).
abstract: Patients with acute myocardial infarction (AMI) with thrombus-laden lesions constitute a revascularization challenge. Thrombus and atherosclerotic plaque absorb laser energy; thus, we studied the safety and efficacy of excimer laser in AMI. In a multicenter trial, 151 patients with AMI underwent excimer laser angioplasty. Baseline left ventricular ejection fraction was 44 +/- 13%, and 13% of patients were in cardiogenic shock. A saphenous vein graft was the target vessel in 21%. Quantitative coronary angiography and statistical analysis were performed by independent core laboratories. A 95% device success, 97% angiographic success, and 91% overall procedural success rate were recorded. Maximal laser gain was achieved in lesions with extensive thrombus burden (p <0.03 vs small burden). Thrombolysis In Myocardial Infarction (TIMI) trial flow increased significantly by laser: 1.2 +/- 1.1 to 2.8 +/- 0.5 (p <0.001), reaching a final 3.0 +/- 0.2 (p <0.001 vs baseline). Minimal luminal diameter increased by laser from 0.5 +/- 0.5 to 1.6 +/- 0.5 mm (mean +/- SD, p <0.001), followed by 2.7 +/- 0.6 mm after stenting (p <0.001 vs baseline and vs after laser). Laser decreased target stenosis from 83 +/- 17% to 52 +/- 15% (mean +/- SD, p <0.001 vs baseline), followed by 20 +/- 16% after stenting (p <0.001 vs baseline and vs after laser). Six patients (4%) died, each presented with cardiogenic shock. Complications included perforation (0.6%), dissection (5% major, 3% minor), acute closure (0.6%), distal embolization (2%), and bleeding (3%). In a multivariant regression model, absence of cardiogenic shock was a significant factor affecting procedural success. Thus, in the setting of AMI, gaining maximal thrombus dissolution in lesions with extensive thrombus burden, combined with a considerable increase in minimal luminal diameter and restoration of anterograde TIMI flow, support successful debulking by excimer laser. The presence of thrombus does not adversely affect procedural success; however, cardiogenic shock remains a predictor of major adverse events during hospitalization.
authors.affiliation: Medical College of Virginia Hospitals, VCU, Richmond, Virginia 23249, USA. on.topaz@med.va.gov
authors.forename: On
authors.initials: O
authors.lastname: Topaz
authors.forename: Douglas
authors.initials: D
authors.lastname: Ebersole
authors.forename: Tony
authors.initials: T
authors.lastname: Das
authors.forename: Edwin L
authors.initials: EL
authors.lastname: Alderman
authors.forename: Hooman
authors.initials: H
authors.lastname: Madyoon
authors.forename: Kishor
authors.initials: K
authors.lastname: Vora
authors.forename: John D
authors.initials: JD
authors.lastname: Baker
authors.forename: David
authors.initials: D
authors.lastname: Hilton
authors.forename: Johannes B
authors.initials: JB
authors.lastname: Dahm
mesh_terms: D016342:Angioplasty, Laser / Q000009:adverse effects; D017023:Coronary Angiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D012501:Saphenous Vein / Q000473:pathology; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014481:United States; D016277:Ventricular Function, Left