Laser Procedure Can Help Some Heart Patients

	July 26, 1999 - Along with the dull, aching pain in his
chest, Robert Seaver would break out in a sweat and have trouble
breathing. Whatever he was doing, he had to stop, sit down, take
a nitroglycerine pill and wait for the angina attack to stop.
"It's scary," he says. "You don't get used to it."
	His doctors were out of options for him. At age 60, Seaver
already had 3 open-heart bypass operations, another surgery to put
in an artificial heart valve, a cath to clean out his arteries and
all the medications that help relieve angina. His heart arteries
were too scarred for another bypass. "He's the kind of patient we
were just telling, 'I'm sorry you have pain, but there's nothing
else wecan do for you,' " says Dr. Mohey Saleh.
	Now there is something else. Saleh does a laser procedure
that drills small holes through the heart wall. That small damage
coaxes the body into building new blood vessels to the heart. The
additional blood eases the shortage of oxygen to the heart that
causes angina. Seaver was the first Dayton-area patient for TMR or
transmyocardial revascularization. Four months later - the time it
takes to grow the new blood vessels - he says, "I'm still alive."
He's not taking nitroglycerin anymore. The TMR hasn't cured him
but he didn't expect that. "It's definitely made a difference,"
he says.
	Thirty hospitals around the country do TMR, which was
approved by the U.S. FDA last August. About 80,000 Americans a year
are diagnosed with severe CAD (coronary artery disease), untreatable
with bypass or angioplasty. With TMR, quality of life for these
patients can be improved. It won't replace standard treatments.
When patients have blocked arteries, surgeons will still try first
to open the blockages with balloon angioplasties or stents, or
reroute the blood with open-heart surgery. There's a limit to how
often that can be done. "The arteries are chewed up all the way
from beginning to end and there's no place to hook up a bypass,"
Saleh says.
	Sometimes medications can control angina. Nitroglycerine
and other drugs dilate the remaining small arteries to increase
blood flow. Beta-blockers and calcium channel blockers slow down
the heart muscles to decrease the demand for blood and its oxygen.
	So TMR is a treatment of last resort. It doesn't require
stopping the heart, and it's done through a 4-inch incision that
doesn't require breaking bones, but it carries the danger of
possibly fatal heart-rhythm irregularities if the computerized
laser bursts aren't properly synchronized with the heart.
	"The complication rate is very high if you do it on
patients who are not stable," Saleh says. Clinical trials back
him up with a death rate of 20% in unstable patients, compared
with 3% otherwise. Saleh won't do TMR on patients still recovering
from heart attacks, for example.
	It usually works well on stable patients. The trials show
70% have had significant reductions in their angina, with an 80%
decrease in hospitalizations. The surgeon typically drills 30 to 40
tiny holes through the muscular heart wall with a carbon-dioxide
laser. The drilling is timed to when the heart is full of blood,
so the blood protects other tissue.
	The notion of creating channels in the heart wall to
increase circulation came from observing reptiles, whose hearts are
nourished that way instead of through arteries outside the heart, like
in humans. As it turns out, Saleh says, the laser-drilled channels
themselves don't deliver more blood to the heart. The body considers
them wounds to the heart and responds by creating new blood vessels
as part of the healing process. "It's the new vessels that increase
the blood flow," Saleh says.
	A less invasive TMR procedure is in experimental stages.
Instead of going through a hole in the patient's chest, the laser is
guided through a catheter threaded through an artery from the groin.
For now, the challenge is making TMR available to everyone who needs
it. These are patients who have exhausted their medical options, so
cardiologists aren't in the habit of sending them to surgeons.